Total Arch Replacement With the Frozen Elephant Trunk Technique

Total aortic arch replacement with the frozen elephant trunk (FET) technique has been an established solution for extended dissections, useful especially in cases where an endovascular approach is not possible (1, 2). The E-Vita Open Neo offers a unique approach for aortic arch replacement with the FET technique. This modern device focuses on getting closer to the distal anastomosis (zones zero, one, and two) instead of the classic zone three, making it even easier. There are three options: straight, branched, and trifurcated. The last method is intended for single-vessel anastomosis of the neck vessels and distal anastomosis at zones zero or one (3). The authors have used this trifurcated configuration for an extended subacute dissection extended from zone zero to the iliac bifurcation as a first step prior to total endovascular repair of the rest of the untreated aorta.

The Patient

A fifty-eight-year-old man presented with sudden and intense abdominal and back pain. A type B aortic dissection with an initial tear at zone three was confirmed by a CT scan. Two weeks later, the patient developed chest pain and a new CT scan showed an extension of the dissection toward the ascending aorta without compromise of the aortic valve but now compromising zone zero. He was transferred to the authors’ institution for treatment.

The Surgery

The aortic dissection was confirmed to be type B extending from zone zero to the iliac bifurcation. The aortic root measured 39 mm, the ascending aorta measured 44 mm, the aortic arch measured 37 mm, and the descending aorta had a maximum diameter of 64 mm.

First, right axillar and femoral artery cannulation was completed with a 21 EOPA cannula in both arteries. Antegrade cerebral perfusion was completed with hypothermic visceral circulatory arrest at 24 degrees. Total ischemia time was 50 minutes.

Next, the aorta was removed from the sinotubular junction to the right carotid artery. The posterior wall of the ascending aorta was then firmly attached to the right pulmonary artery. A pulmonary artery closure with a pericardial patch was needed. A wire coming from the right femoral artery was captured and introduced to the E-vita Open Neo device. This was mandatory to reach the true lumen of the thoracic aorta.

The device selected had an endograft of 180 mm x 33 mm. The Dacron graft presented four branches that includes one of 10 mm for the left subclavian, 8 mm for the left carotid artery, 12 mm for the brachiocephalic trunk, and 10 mm for visceral perfusion. The Dacron graft for the ascending aorta was a 30 mm x 100 mm graft. A running suture was performed to attach the graft to the aorta.

Next, anastomosis of both the right carotid artery and brachiocephalic was performed on their respective branches. The next step was the proximal anastomosis at the sinotubular junction. An extra-anatomic anastomosis of the 12 mm branch to the left subclavian artery was performed. Each supra-aortic vessel was ligated at the origin.

The false lumen collapsed immediately at the end of the procedure. This was confirmed with transesophageal echocardiography. The patient did not bleed and had proper cardiac output but presented with paraplegia after 48 hours, which was treated with by keeping a MAP of more than 90-100 mmHg, Hb over 100 mg, and spinal drain with a controlled output of 10 ml/hr. The patient had partial recovery. These undesirable complications unfortunately can occur in 5 percent of patients undergoing FET. Neurological complications can occur in 6.2 percent of patients, as was described in a metaanalysis by Moulakakis et al (4).

In this patient, a thorax CT scan showed how the stent graft collapsed the false lumen with a notorious improvement. In conclusion, the FET with the trifurcated E-vita Open Neo is a valid option for complex acute, subacute, and chronic aortic dissections.

References

1. Czerny M, Schmidli J, Adler S, et al. Editor’s choice - current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: An expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2019;57:165e98.
2. Czerny M, Pacini D, Aboyans V, et al. Current options and recommendations for the use of thoracic endovascular aortic repair in acute and chronic thoracic aortic disease: An expert consensus document of the European Society for Cardiology (ESC) working group of cardiovascular surgery, the ESC work- ing group on aorta and peripheral vascular diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2021;59:65e73.
3. Rorris F, Antonopoulos C, Fissis I, et al. E-Vita Open Neo Hybrid Stent Graft: A New Frontier for Total Arch Replacement. Ann Vasc Surg 2022; 84: 211–217 https://doi.org/10.1016/j.avsg.2022.01.034.
4. Moulakakis KG, Mylonas SN, Markatis F, et al. A systematic review and meta-analysis of hybrid aortic arch replacement. Ann Cardiothorac Surg 2013;2:247-60.

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