Root and Total Arch Replacement and Frozen Elephant Trunk In Aortic Dissection: How We Do It

This video details the operative steps and technique of root and total arch replacement with frozen elephant trunk for aortic dissection, as described by Dr Sun (1). Right axillary cannulation with selective antegrade cerebral perfusion for brain protection and moderate hypothermic circulatory arrest at 25 °C is used. A special open-stented graft, endowed with a two centimeters regular Dacron cuff attached at both ends, is used. This device allows the authors to suture a 4-branched vascular graft for proximal reconstruction and facilitates second-stage repair of the descending aorta. The device is inserted into the descending aorta, and total arch replacement is performed using a particular anastomotic sequence (i.e., proximal descending aorta → left carotid artery → ascending aorta → left subclavian artery → innominate artery). Early rewarming and lower body perfusion via the fourth branch of the graft is achieved. A Cabrol shunt is used to minimize blood losses.

Since its introduction in 2003, this technique procedure has been performed in over 8,000 patients in China with in-hospital mortality rate as low as 4% for elective and 7% for emergent cases, and satisfactory long-term outcomes (1, 2).

The main advantage of this technique lies in the technical simplicity, minimization of cerebral and cardiac ischemia, and the possibility to suture directly another graft for proximal reconstruction or in second stage descending repair.

References

1. Ma WG, Zhu JM, Zheng J, Liu YM, Ziganshin BA, Elefteriades JA, et al. Sun's procedure for complex aortic arch repair: total arch replacement using a tetrafurcate graft with stented elephant trunk implantation. Ann Cardiothorac Surg. 2013 Sep;2(5):642-648.
2. Ma WG, Chen Y, Zhang W, Li Q, Li JR, Zheng J, et al. Limited versus extended repair for acute type A aortic dissection: long-term outcomes of the Beijing approach beyond 10 years. J Cardiovasc Surg (Torino). 2020 Feb 18. Epub ahead of print.

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