Multibranched hybrid device for frozen elephant trunk: What does it change?

Abstract

See related commentary pages 255-7. See related commentary pages 255-7. Introduced in 1996, the frozen elephant trunk is a technique that allows the treatment of degenerative and chronic dissecting aneurysms involving the aortic arch and the proximal descending aorta.1Kato M. Ohnishi K. Kaneko M. Ueda T. Kishi D. Mizushima T. et al.New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft.Circulation. 1996; 94: II188-II193PubMed Google Scholar During recent years, various hybrid prostheses have been developed. Reported series have shown satisfactory perioperative and midterm results of the frozen elephant trunk.2Ius F. Fleissner F. Pichlmaier M. Karck M. Martens A. Haverich A. et al.Total aortic arch replacement with the frozen elephant trunk technique: 10-year follow-up single centre experience.Eur J Cardiothorac Surg. 2013; 44: 949-957Crossref PubMed Scopus (70) Google Scholar, 3Verhoye J.P. Anselmi A. Kaladji A. Flécher E. Lucas A. Heautot J.F. et al.Mid-term results of elective repair of extensive thoracic aortic pathology by the Evita Open Plus hybrid endoprosthesis only.Eur J Cardiothorac Surg. 2014; 45: 812-817Crossref PubMed Scopus (9) Google Scholar The Thoraflex prosthesis (Vascutek Terumo, Inchinnan, UK) is a new device with selective supra-aortic branches and a sewing collar (Figure 1). We present our initial experience with the Thoraflex device in 6 patients with various chronic aortic pathologies (Table 1).Table 1Patients and procedural dataCaseThoracic aorta diseasePrevious cardiac operationAssociated procedureLanding zone diameter (mm)Thoraflex device size (mm)Arterial cannulationCPB time (min)ACC time (min)CA time (min)ACP time (min)SAV reimplantation technique1Chronic dissectionAAR and AVRpNone2426/28/150AxA2151296287En bloc2AneurysmNoneAAR and AVRp3130/36/150AAo and FemA2111077∗In this case, visceral perfusion was realized through a femoral artery cannula.92Separate3AneurysmNoneAAR and AVR2930/34/150AAo2031085477Separate4Chronic dissectionAAR and AVRpNone2830/32/150AAo197974688Separate5AneurysmNoneCABG2426/28/100AxA206895081Separate6Chronic dissectionNoneBentall3432/40/150AAo25518783166SeparateCPB, Cardiopulmonary bypass; ACC, aortic crossclamp; CA, circulatory arrest; ACP, antegrade cerebral perfusion; SAV, supra-aortic vessels; AAR, ascending aorta replacement; AVRp, aortic valve repair; AxA, axillary artery; AAo, ascending aorta; FemA, femoral artery; AVR, aortic valve replacement; CABG, coronary artery bypass grafting.∗ In this case, visceral perfusion was realized through a femoral artery cannula. Open table in a new tab CPB, Cardiopulmonary bypass; ACC, aortic crossclamp; CA, circulatory arrest; ACP, antegrade cerebral perfusion; SAV, supra-aortic vessels; AAR, ascending aorta replacement; AVRp, aortic valve repair; AxA, axillary artery; AAo, ascending aorta; FemA, femoral artery; AVR, aortic valve replacement; CABG, coronary artery bypass grafting. The Thoraflex hybrid prosthesis (Figure 2, A and B) is used for aortic arch and descending aorta replacement during moderate hypodermic circulatory arrest (26°C) and antegrade selective cerebral perfusion (10 mL/kg/min). The stented portion of the Thoraflex graft can be slightly shaped to conform to the anatomy of the descending thoracic aorta and pushed down over a guidewire (Figure 2, C). The handle is used to stabilize the graft in the correct position, paying attention to the right cranial position of supra-aortic vessel branches. The sheath is retracted back through the splitter to deploy the self-expanding stent. The splitter is then removed, and a sewing collar is freed at the junction between the stented and unstented segments. The guidewire is pulled back and the distal stented part completely opened, releasing the red clip on the top of the delivery system. Finally, the delivery system is removed from the hybrid graft. The distal aortic anastomosis at the aortic isthmus is performed first, thanks to the sewing collar, with a 4-0 running Prolene suture (Ethicon, Inc, Somerville, NJ). Once this anastomosis has been completed, the cardiopulmonary bypass arterial line is connected to the side branch of the graft for antegrade distal organ perfusion and rewarming. The proximal aortic anastomosis is then performed with a 4-0 running Prolene suture between the unstented graft and the prosthesis previously sutured, to replace the ascending aorta. The supra-aortic vessel anastomoses are performed after aortic declamping and during rewarming, starting from the left subclavian artery with selective use of the 3 specific branches of the graft. Subsequently, the patient is weaned from cardiopulmonary bypass. A representative postoperative contrast computed tomographic result (case 4) is shown in Figure 2, D. Hybrid prostheses enable completion of aortic surgical repair in a single stage, thus avoiding the cumulative mortality and interval mortality associated with 2-stage approaches. A systematic review of 17 studies identified pooled mortality and stroke rate in 2-stage procedures of 8.3% and 4.9%, respectively.4Tian D.H. Wan B. Di Eusanio M. Black D. Yan T.D. A systematic review and meta-analysis on the safety and efficacy of the frozen elephant trunk technique in aortic arch surgery.Ann Cardiothorac Surg. 2013; 2: 581-591PubMed Google Scholar Cardiopulmonary bypass time, myocardial ischemia time, and circulatory arrest time were strongly correlated with mortality. The multibranched Thoraflex stent-graft offers several new technical innovations relative to other designs.5Yan T.D. Field M. Tian D.H. Bashir M. Oo A. Aortic root and total arch replacement with frozen elephant trunk procedure, using a Thoraflex Hybrid Graft.Ann Cardiothorac Surg. 2013; 2: 667-668PubMed Google Scholar First, it is a short and handy device with an easy deployment system. Different sizes of the stented and unstented segments are provided for a better fit with aortic anatomy. Thanks to the malleable shaft, the stented part can be shaped to conform to the isthmus and descending aorta anatomy. This makes the device less traumatic on the descending aortic wall and easier to introduce into the aorta. The sewing collar between the Dacron polyester fabric tube and the stented segment ensures easier and safer anastomosis of the prosthesis to the aortic isthmus, reducing the hemodynamic traction on the anastomosis itself and allowing further hemostatic stitches, when necessary, even at the end of the procedure. The grafts' branches allow separate reimplantation of the supra-aortic vessels, enabling shorter ischemic visceral and myocardial durations, although en bloc reimplantation remains possible. Separate reimplantation also allows better individual hemostatic control of supra-aortic vessel anastomoses, including the isthmus anastomosis. This technique for arch vessels may be relevant when their origins are distant from each other or dissected and in patients for whom a radical aortic resection may be needed, such as those with connective diseases or severe calcifications or clots at the proximal portions of the vessels. In some cases, the left subclavian anastomosis may be difficult to perform because of the closed position of the branch to the corresponding vessel and may need to be realized before the pump is restarted. This can minimally increase the visceral ischemic time. Finally, the radiopaque markers in the stented portion of the Thoraflex prosthesis further simplify endovascular completion when necessary. After this initial experience, we consider the Thoraflex hybrid prosthesis to be a versatile device representing a suitable alternative for management of complex chronic aortic pathologies involving the arch and the proximal descending aorta. The authors are grateful to Dr Agnino and to the members of CardioMiss Association for their invaluable help and outstanding support in the development of this aortic surgery program. Four-branched graft with stent hybrid prosthesis for single-stage treatment of chronic aortic arch pathologyThe Journal of Thoracic and Cardiovascular SurgeryVol. 150Issue 1PreviewTreating chronic aortic arch pathologies such as dissection and aneurysm can be quite complex because typically it involves addressing the aortic arch and the proximal descending thoracic aorta (DTA). Single-stage operation for this pathology requires a thoracosternotomy incision to replace the aortic arch and the proximal DTA. Given the high comorbidity associated with such an extensive operation, several groups advocate for a 2-stage procedure, where the aortic arch is replaced first using an elephant trunk technique followed by open DTA replacement via a thoracotomy or retrograde thoracic endovascular aortic repair (TEVAR) by stent grafting of the DTA. Full-Text PDF Open Archive