Elephant Trunk Graft Research Articles

In situ laser fenestration of aortic septum to bridge false and true lumen during endovascular repair of aortic dissection

Fenestration of the septum between the true and false lumen might be necessary after aortic dissection. We report the technical aspects of in situ laser fenestration of the aortic dissection septum. Two illustrative cases are provided: a 56-year-old man with false lumen deployment of a frozen elephant trunk graft, and a 67-year-old man who underwent fenestrated endovascular aortic repair with a target branch vessel off the false lumen. In both cases, the septum was crossed using in situ laser fenestration. This technique is a precise option to enable passage between true and false lumens during endovascular repair of an aortic dissection.

Intermediate outcomes following arch reconstruction with frozen elephant trunk, a single centre study

BackgroundSurgery on the aortic arch and proximal descending thoracic aorta can be lifesaving but is also associated with significant morbidity, ranging from minor infections to severe neurological impairments as well as a substantial risk of mortality. The aim of this study is to clinically assess outcomes, with special regards to neurologic injury, as well as to seek to identify predictors of in-hospital mortality in two patient groups with different underlying aortic pathology, aneurysms and dissections, undergoing arch/descending aortic repair.Methods34 patients (17 aneurysms, 17 dissections) underwent surgery involving the arch and/or descending aorta, using the Thoraflex or E-Vita frozen elephant trunk graft. 40% were female. Subgroup analysis of aneurysms compared to dissections were performed. Mean follow-up time was 53.9 months and mean age 63.5 years.ResultsIn-hospital mortality was 18%. Survival was comparable between aneurysms and dissections. Incidence of spinal cord injury was 9% and stroke 9%. 67% suffered any form of neurological affection, when also cognitive afflictions were included. Perioperative reoperation rate was 29% (bleeding 21%, visceral ischemia 6%, infection 2%), the need for postoperative dialysis was 11% and a series of other minor complications such as atrial fibrillation and pleurocentesis were common.ConclusionPostoperative dialysis was found to be a predictor of in-hospital mortality, while both dialysis as well as reoperation due to bleeding and/or visceral ischemia increased the risk for overall mortality, irrespective of preoperative diagnosis. Previous or current smoking appeared to be associated with negative outcomes regarding both in-hospital and overall mortality during follow-up.Trial registration Retrospectively enrolled.

Total Aortic Arch Replacements With a 4 Branched Frozen Elephant Trunk (FET) Graft in Acute Aortic Dissection (DeBakey type I)

Total Aortic Arch Replacements With a 4 Branched Frozen Elephant Trunk (FET) Graft in Acute Aortic Dissection (DeBakey type I)

On-table fenestration of frozen elephant trunk graft to achieve aberrant subclavian artery perfusion.

On-table fenestration of frozen elephant trunk graft to achieve aberrant subclavian artery perfusion.

New anatomical frozen elephant trunk graft for zone 0: endovascular technology reduces invasiveness of open surgery to the max.

The first-in-man implant of a custom-made branched frozen elephant trunk graft designed for an anastomosis in aortic arch zone 0 is reported. Combining endovascular technology with open surgical techniques has allowed for simplification of the open procedure with substantial reduction in circulatory arrest time and in the extent of the surgical preparations.

Spinal cord injury during selective cerebral perfusion and segmental artery occlusion: an experimental study.

Since selective cerebral perfusion (SCP) has been used in aortic arch surgical procedures, the core temperature during lower body circulatory arrest (LBCA) has been steadily rising. Simultaneously, the use of a frozen elephant trunk (FET) graft has been increasing. The safe period of LBCA in relation to spinal cord ischaemic tolerance in combination with segmental artery occlusion by the FET procedure has not been defined. Sixteen pigs were assigned to undergo 65 (n = 10) or 90 min (n = 6) of SCP at 28°C with LBCA in combination with occlusion of the 8 uppermost segmental arteries in the thoracic (Th) aorta (15-20 cm FET, Th8-level). The follow-up period consisted of a 6-h intensive period and a 5-day observation period. Near-infrared spectroscopy of the collateral network was used to determine spinal cord oxygenation. The neurological status of the patients was evaluated daily, and the brain and the spinal cord were harvested for a histopathological analysis. Five out of 6 pigs after 90 min and 1 out of 10 pigs after 65 min of LBCA died within 48 h of multiorgan failure. Of the survivors in the 65-min group, 6 out of 9 had paraparesis/paraplegia; the remaining 3 reached normal function. The lone survivor after 90 min of LBCA was paraplegic. Nadir near-infrared spectroscopy of the collateral network values at Th8 and Th10 were 34 (±5) and 39 (±4), and they were reached within 35 min of SCP in both groups. An extended FET graft with LBCA and SCP durations >65 min at 28°C results in a poor outcome.

First-in-Human Use of the Cook Hybrid Frozen Elephant Trunk Graft: The Canadian Experience

Advancements in technology have changed the treatment of aortic arch pathologies. Specifically, the introduction of the frozen elephant trunk technique has allowed one-stage treatment of pathologies that would have otherwise required a two-stage procedure. We present the early outcomes of a novel frozen elephant hybrid stent graft. Between August 2015 and July 2019, 39 patients (56% male; mean age 67 ± 11years) underwent an arch reconstruction with a novel hybrid stent graft in four different Canadian centers. The most common indication for surgery was arch aneurysm (31%) followed by acute dissection (28%). All patients were prospectively followed with clinical and imaging assessments. The device was successfully implanted in all patients. There were 3 perioperative deaths (8%). Transient spinal cord injury occurred in 5 patients (13%); all had complete neurologic recovery before discharge. Seven patients had a perioperative stroke/transient ischemic attack; 3 of them initially presented with cerebral malperfusion caused by acute dissection. One patient died during the study follow-up. Survival at 30 days and at 1 and 3 years was 92% ± 5%, 89% ± 5%, and 89% ± 5%, respectively. At a median follow-up of 16 months, 3 patients required a reintervention to address a type I distal endoleak and 1 patient was treated for a type II endoleak. There was no arch anastomosis complications. The Cook hybrid stent graft device provides encouraging midterm results in a high-risk cohort. This novel graft is simple to deploy, may be customized to patients' anatomy in elective cases, eases arch reconstruction, and allows versatility in the choice of arch grafts.

Mild Systemic Hypothermic Circulatory Arrest Using a Frozen Elephant Trunk Graft with Endo-Balloon Occlusion for Total Arch Replacement.

Stroke and paraplegia are serious complications of total aortic arch replacement (TAR). Hypothermic circulatory arrest and cerebral perfusion reduce the risk of neurologic complications, but longer circulatory arrest time remains a risk factor for such complications. We utilized a frozen elephant trunk (FET) with endo-balloon occlusion under mild systemic hypothermia, which allowed us to shorten circulatory arrest time. Between April 2007 and May 2020, 72 patients underwent elective TAR using antegrade cerebral perfusion (ACP). They were divided into 2 groups. 64 patients received conventional TAR with moderate systemic hypothermic (bladder temperature, 25-28°C) circulatory arrest (group C). We used a FET with endo-balloon occlusion and retrograde perfusion through the femoral artery for the newest 8 patients who had mild hypothermic (bladder temperature of 30°C) circulatory arrest (group B). The mean operation time (257.5 ± 42.1 versus 327.8 ± 84.9 min, P = .023), CPB time (144.4 ± 28.1 versus 178.2 ± 26.4 min, P = .003), cardiac arrest time (75.5 ± 21.2 versus 95.7 ± 56.4 min, P < .001), SCP time (100.8 ± 25.5 versus 124 ± 23.2 min, P < .001), lower body circulation arrest time (17.2 ± 4.2 versus 62.5 ± 19.3 min, P < .001) were significantly shorter in the endo-balloon occlusion group. There were no perioperative neurological and renal complications or mortality in FET group. The new technique enabled a decrease in mechanical ventilation time (8.6 ± 1.4 versus 13.9 ± 5.7 min, P = .015) and hospital length of stay (9.7 ± 1.8 versus 18.3 ± 4.6 min, P = .005). FET using an endo-balloon occlusion with mild hypothermia is a safe and an effective approach in TAR.

Type B aortic dissection repair using a Thoraflex hybrid prosthesis in a setting of aberrant left vertebral artery

AbstractType B aortic dissection (TBAD) is often managed conservatively with intervention reserved for complicated cases. Strategies for complicated and uncomplicated TBAD can involve optimal medical therapy, thoracic endovascular aortic replacement and open surgical repair of TBAD with replacement of the affected segment of aorta and reimplantation of aortic branches. The frozen elephant trunk technique has been reported to be a successful surgical strategy in patients with complicated TBAD, particularly in patients who possess unfavourable aortic arch anatomy for endovascular stenting or at increased risk of retrograde Type A aortic dissection. The Thoraflex is a commercially available aortic graft, manufactured by Vascutek®. We describe a successful case of addressing complicated TBAD with rare variant aortic anatomy using a Thoraflex hybrid frozen elephant trunk graft and reimplantation of the aberrant left vertebral artery to the perfusion limb of the Thoraflex graft.

One-stage aortic replacement for type A aortic dissection: using a Vasoring and a conventional elephant trunk graft.

We used a vascular ring connector (Vasoring) and a conventional elephant trunk graft for complete repair in open surgery for type A aortic dissection. This report described the immediate and mid-term results of this new technique. We used a rigid titanic ring as a stent in the vascular graft for rapid sutureless anastomosis in the reconstruction of type A aortic dissection. A total of 65 consecutive patients with Stanford type A aortic dissection underwent open surgery performed by a single surgeon from November 2007 to February 2017. All patients underwent aortic reconstruction with vascular grafts and Vasorings (21 patients in the ascending aorta and 44 patients in the total aortic arch). For total aortic arch replacement, we implanted the conventional vascular graft in the proximal descending thoracic aorta as an elephant trunk graft. Concomitant procedures included the Bentall procedure (9 patients), the David operation (6 patients), coronary artery bypass grafting (9 patients), heart transplantation (1 patient), mitral valve replacement (2 patients) and endovascular aortic repair (1 patient). The mean duration of postoperative endotracheal intubation was 17.0 ± 11.8 h. The average blood loss was 520 ± 743 ml, and 25% of patients required no blood transfusion. The in-hospital mortality rate was 6%. The combined use of the vascular ring connector and the conventional elephant trunk graft may reduce bleeding and pump time, stop the blood flow in the false lumen and allow the 1-stage total arch replacement to be performed safely. The conventional elephant trunk graft is free from stent graft-induced new entry.

Buffalo Trunk: Using Available Materials to Mimic the Benefits of a Hybrid Elephant Trunk Graft

Eldeiry, Mohamed MD; Aftab, Muhammad MD; Cleveland, Joseph C. MD, FACS; Fullerton, David A. MD, FACS; Reece, T. B. MD Author Information

Repair of Infective Thoracic Aortic Aneurysm Ruptured in the Lung Using Total Arch Replacement with a Frozen Elephant Trunk Graft

Repair of Infective Thoracic Aortic Aneurysm Ruptured in the Lung Using Total Arch Replacement with a Frozen Elephant Trunk Graft

Reversed Frozen Elephant Trunk Technique to Treat a Type II Thoracoabdominal Aortic Aneurysm

Purpose: To describe a hybrid technique of reversed frozen elephant trunk to treat thoracoabdominal aortic aneurysms (TAAA) through an abdominal only approach. Technique: The technique is demonstrated in a 29-year-old Marfan patient with a chronic type B aortic dissection previously treated with a thoracic stent-graft who presented with a thoracoabdominal false lumen aneurysm. Through an open distal retroperitoneal approach to the abdominal aorta, a frozen elephant trunk graft was implanted over a super-stiff wire upside down with the stent-graft component in the thoracic aorta. Following deployment of the stent-graft proximally and preservation of renovisceral perfusion in a retrograde manner, the renovisceral vessels were sequentially anastomosed to the elephant trunk graft branches, thus reducing the ischemia time of the end organs. The aortic sac was then opened, and the distal part of the hybrid graft was anastomosed with a further bifurcated graft to the iliac vessels. Conclusion: The reversed frozen elephant trunk technique is feasible for hybrid treatment of TAAAs via an abdominal approach only. This has the benefit of substantially reducing the trauma of thoracic exposure, thus preserving major benefits of open thoracoabdominal surgery, such as the presence of short bypasses to the renovisceral vessels and reimplantation of lumbar arteries to reduce spinal cord ischemia.

Frozen elephant trunk surgery using the Vascutek Thora-flex hybrid prosthesis.

The Vascutek Thoraflex hybrid graft (Vascutek, Scotland) is a novel commercially available 4-branched frozen elephant trunk (FET) graft used to treat patients with extensive diseases of the thoracic aorta (1). This hybrid prosthesis is composed of a distal endograft sealed to a proximal 4-branched gelweave graft with an incorporated sewing collar (Figure 1). Figure 1 The Vascutek Thora-flex hybrid prosthesis The text of this manuscript describes our FET technique with the Vascutek Thoraflex hybrid graft in detail (Video 1). Video 1 Frozen elephant trunk surgery using the Vascutek Thora-flex hybrid prosthesis Clinical vignette A 73-year-old man who had undergone a supra-coronary ascending aorta replacement for a DeBakey type 1 acute aortic dissection in a different Institution in 1997 was recently referred to our hospital for a residual chronic post-dissection aneurysm of the thoraco-abdominal aorta. Upon admission, the angio CT scan showed severe dilatation of the thoracic (48 mm) and abdominal (72 mm) aorta. The false lumen of the abdominal aorta was completely thrombosed; all the visceral vessels originated from the true lumen of the dissection with the exception of the left renal artery; large intimal tears were identified at the origin of the innominate artery and at the level of distal descending thoracic aorta. The native aortic root measured 33 mm (Figure 2). A trans-thoracic echocardiogram showed a competent tricuspid aortic valve and a normal left ventricular ejection fraction (62%). The preoperative coronary angiogram revealed severe 3-vessel coronary artery disease with critical stenoses of the left anterior descending, obtuse marginal and right coronary arteries. Figure 2 Angio CT image showing the residual DeBakey type 1 aortic dissection of the thoraco-abdominal aorta The patient was scheduled for a 3-staged hybrid treatment involving complete arch replacement with the FET and myocardial revascularization (stage 1), replacement of the abdominal aorta with visceral vessel de-branching (stage 2), and endovascular stenting of the remaining aortic segments from the FET to the abdominal aortic graft (stage 3). This video focuses on the stage-one procedure.

Elephant trunk technique for hybrid aortic arch repair

The original elephant trunk technique was developed by Borst in 1983 for the treatment of aortic arch aneurysms. This technique reduced operative risks, but was associated with cumulative mortality rates of 6.9% for the first stage and 7.5% for the second stage. Patients also waited a long time between two major surgical procedures. Only 50.4% of patients underwent the second-stage surgery, and there was a significant interval mortality rate of 10.7%. With the advent of stent-graft techniques, two different hybrid elephant trunk techniques were developed. One technique is first-stage elephant trunk graft placement followed by second-stage endovascular completion. The conventional elephant trunk graft provides a good landing zone for the stent-graft, and endovascular completion is a useful alternative to conventional second-stage surgery. This method has few major complications, and a postoperative paraplegia rate of 1.1%. The other technique is the frozen elephant trunk technique. This technique eliminates the need for subsequent endovascular completion, and is particularly useful for the treatment of acute type A dissection because it can achieve a secure seal. However, it is associated with a higher rate of spinal cord ischemia than other methods such as the original elephant trunk technique. The left subclavian artery (LSA) is often lost when performing a hybrid elephant trunk procedure. Revascularization of the LSA should be performed to prevent arm ischemia and neurological complications such as paraplegia or stroke, although the level of evidence for this recommendation is low.

Total Arch Replacement with Stented Elephant Trunk in DeBakey Type I Acute Aortic Dissection

A 67-year-old female patient was treated with conventional total arch replacement and insertion of a stented elephant trunk (SET) graft into the descending thoracic aorta for acute DeBakey type I aortic dissection at one time. She had been treated with right coronary artery stent insertion for acute myocardial infarct 4 days earlier, and at that time, she was diagnosed with acute DeBakey type I aortic dissection from the ascending aorta to the suprarenal artery based on trans-esophageal echocardiography and aorta computed tomography. Through a median sternotomy, we inserted the SET graft through the opened aorta to the descending aorta. We also performed anastomosis between the proximal stented graft and the distal aortic arch, and then performed total arch replacement. For acute DeBakey type I aortic dissection, we report total arch replacement with insertion of a SET graft as a combination of conventional surgery and the interventional technique.

Factors predictive of distal stent graft-induced new entry after hybrid arch elephant trunk repair with stainless steel–based device in aortic dissection

Stent graft-induced new entry (SINE) has been increasingly observed after thoracic endovascular aortic repair of aortic dissection. We illustrate the possible mechanism by exploring predictive factors of late distal SINE after hybrid arch elephant trunk repair for aortic dissection. From November 2006, to May 2011, 20 of 99 patients underwent hybrid arch repair using the elephant trunk graft as the proximal landing zone. After a mean follow-up period of 27.9 ± 12.0 months, 12 patients had late distal SINE events and the others were free of events. False lumen remodeling level was observed and maximal longitudinal diameter, average of longitudinal and transverse maximal diameter, circumference, and area of true lumen were analyzed for precise size selection of stent graft before and after the procedure. Taper ratio, true lumen:aorta ratio, prestent grafting oversizing ratio, poststent grafting oversizing ratio, and expansion mismatch ratio of distal true lumen were proposed and calculated for further evaluation of the mechanism of late distal SINE. Only the area oversizing ratio between true lumen and the distal selected stent graft at the presumed distal end of stent grafting was found as a significant predictive factor of SINE before procedure (4.00 ± 2.96 vs 1.98 ± 0.66 for SINE vs non-SINE, respectively; P = .031). The significant difference of the expansion mismatch ratio of true lumen between the 2 groups was found not only in the size measurement of mean diameter (1.48 ± 0.29 vs 1.22 ± 0.15; P = .039), but also in the area (2.39 ± 0.85 vs 1.58 ± 0.42; P = .031) and circumference (1.43 ± 0.27 vs 1.18 ± 0.14; P = .016) after stent grafting. We found that taper ratio is not an optimal criteria for stent graft size selection and distal oversizing calculated by true-lumen area is a significant factor causing delayed distal SINE. Use of the prestenting area oversizing ratio should be limited.

Total aortic arch replacement with a novel four-branched frozen elephant trunk graft: first-in-man results†

The combined disease of the aortic arch and the proximal descending aorta remains a surgical challenge. With the 'frozen elephant technique', the ascending aorta, along with the aortic arch, is replaced conventionally and an endovascular stent graft is placed into the descending aorta in the antegrade manner through the open aortic arch, thereby potentially allowing for a 'single-stage' operation. The purpose of this study was to assess the feasibility of a novel four-branched hybrid graft (Vascutek, Scotland). From April 2010 to August 2011, 34 patients (25 males, age 60 ± 14 years) were operated on [14 aneurysms, 20 dissections (18 acute)]. Ten of these patients had undergone previous cardiac operations. The collapsed endoprosthesis was deployed in the descending aorta through the opened aortic arch. A sewing collar between the graft segments simplified the 'distal' anastomosis. The four-branched graft segment allowed the replacement of the aortic arch and supra-aortic vessels individually. Concomitant procedures were performed if necessary. There were three deaths within the 30 postoperative days. All of them were of AADA patients. The mean cardiopulmonary bypass time was 254 ± 53 min, aortic cross clamp time was 148 ± 48 min and circulatory arrest time was 48 ± 22 min. Aortic valve-sparing root surgery was performed in 12 patients, Bentall procedure in four, CABG in three and mitral valve repair in two. In one patient, a secondary endovascular extension of the stent graft was necessary to reach the landing zone. In all others, postoperative CT-Scans confirmed the desired results. The graft adds to the 'frozen elephant trunk' concept for treating the arch and proximal descending aorta. Early experience demonstrates an excellent 30-day survival. Combining the frozen elephant with a four-branched arch graft increases the armament of the surgeon in the treatment of complex and diverse aortic arch pathology.

Total aortic arch replacement with 4-branched frozen elephant trunk graft

Total aortic arch replacement with 4-branched frozen elephant trunk graft

Invited Commentary

Traditional surgical approaches for repair of the aortic arch, including hypothermic circulatory arrest, are under attack. The standard surgical paradigm for addressing complex arch pathologies is being challenged by less-invasive alternatives. The catalysts for this uprising are endovascular technologies that leave the aortic arch in tact and “exclude” the diseased aortic segment from pressurized arterial flow. This is in contradistinction to the fundamental surgical principles of “resecting” the diseased aortic arch segment and replacing it with an interposition synthetic graft. A new branch of aortic surgery has subsequently evolved, termed hybrid repair, which involves combining the advantages of open surgery with the less-invasive principles of endovascular repair. It is this marriage of contrasting principles that is challenging the tenets of established aortic disease management and treatment. The real question is whether this a marriage of convenience is doomed to failure or if this is a match made in heaven? There is some disagreement as to how to best combine surgical repair of the aortic arch with endovascular technologies. At its root, there are two different techniques that have evolved, and a new nomenclature for hybrid arch repair has been developed to facilitate appropriate classification of these different approaches [1Kouillias G.J. Wheatley G.H. State-of-the-art of hybrid arch procedures: a meta-analysis.Ann Thorac Surg. 2010; 90 (689–7)Google Scholar]. The nomenclature is based on whether the arch is resected or left intact. Type I hybrid arch repair involves standard elephant trunk repair with downstream placement of the endovascular stent-graft into the distal elephant trunk graft. Type II hybrid arch repair involves extra-anatomic revascularization of the great vessels and endovascular stent-graft exclusion of the diseased aortic arch. The article by Lee and colleagues [2Lee C.W. Beaver T.M. Klodell C.T. et al.Arch debranching versus elephant trunk procedures for hybrid repair of thoracic aortic pathologies.Ann Thorac Surg. 2011; 91: 465-471Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar] compares the outcomes of type I hybrid arch repair versus type II hybrid arch repair. At the heart of the discussion is whether the type II approach adequately treats the aortic pathology and whether extra-anatomic revascularization of the great vessels provides adequate preservation of cerebral blood flow. In this single-center study, 21 patients underwent elephant trunk reconstruction of the aortic arch and 37 patients underwent extra-anatomic reconstruction of the great vessels. There were no differences in complication rate between either group for the first stage to the hybrid repair. During the second stage endovascular repair, the elephant trunk group had a 3-fold higher complication rate. After appropriate comparisons were made between the two groups, there were no statistical differences between the groups in terms of outcomes, but the combined length of hospital stays were statistically shorter in the type II hybrid arch repair group. In a small series study of patients, this article has confirmed that type II hybrid arch repair is a viable alternative to type I repair. Outcomes for both groups were equivalent at 12 months. Although longer-term follow-up and comparisons will be necessary, it seems that based on this study, along with others, the less-invasive type II hybrid arch repair is a safe alternative. At this point, it is possible that type II hybrid arch repair may be more appropriate in higher-risk surgical patients, although this study did not select which patients would receive type I versus type II repair, based on comorbidities. Additional studies will be needed to validate the hybrid arch repair paradigm. Arch Debranching Versus Elephant Trunk Procedures for Hybrid Repair of Thoracic Aortic PathologiesThe Annals of Thoracic SurgeryVol. 91Issue 2PreviewWe compared outcomes of arch debranching (AD) and elephant trunk (ET) techniques when used with thoracic endovascular aortic repair. Full-Text PDF