Four-branched Graft Research Articles

Surgical treatment strategies for patients with type A aortic dissection involving arch anomalies.

ObjectiveThe aim of the study was to investigate surgical modalities and outcomes in patients with type A aortic dissection involving arch anomalies.MethodPatients with type A aortic dissection who underwent surgical treatment at our center between January 2017 and 31 December 2020 were selected for this retrospective analysis. Data including computed tomography (CT), surgical records, and cardiopulmonary bypass records were analyzed. Perioperatively survived patients were followed up, and long-term mortality and aortic re-interventions were recorded.ResultA total of 81 patients with arch anomalies were included, 35 with “bovine” anomalies, 23 with an aberrant right subclavian artery, 22 with an isolated left vertebral artery, and one with a right-sided arch + aberrant left subclavian artery. The strategies of arch management and cannulation differed according to the anatomic variation of the aortic arch. In total, seven patients (9%) died after surgery. Patients with “bovine” anomalies had a higher perioperative mortality rate (14%) and incidence of neurological complications (16%). Overall, four patients died during the follow-up period, with a 6-year survival rate of 94.6% (70/74). A total of four patients underwent aortic re-intervention during the follow-up period; before the re-intervention, three received the en bloc technique (13.6% 3/22) and one received hybrid therapy (11.1% 1/9).ConclusionWith complete preservation and reconstruction of the supra-arch vessels, patients with type A aortic dissection combining arch anomalies can achieve a favorable perioperative prognostic outcome. Patients who received the en bloc technique are more likely to require aortic re-intervention than patients who underwent total arch replacement with a four-branched graft vessel. Cannulation strategies should be tailored according to the variation of anatomy, but routine cannulation with the right axillary artery can still be performed in most patients with arch anomalies, even for patients with an aberrant right subclavian artery.

Four-branched graft inversion technique for the distal anastomosis in acute aortic dissection

BackgroundDistal anastomosis bleeding is an issue during total arch replacement with the frozen elephant trunk technique. We used the 4-branched graft inversion technique for the distal anastomosis in acute aortic dissection. The aim was to evaluate the feasibility and benefits of the technique used during the frozen elephant trunk procedure for acute aortic dissection.MethodsFrom January 2017 to July 2019, 109 patients underwent total arch replacement for type A acute aortic dissections. Patients were divided according to the technique used for the distal anastomosis as follows: group G (n = 57; 4-branched graft inversion technique) and group C (n = 52; conventional method with Teflon felt). The postoperative variables were analysed.ResultsThe hospital mortality rate was 9.2% (10/109). The mean cardiopulmonary bypass, cardiac arrest, and circulatory arrest times were 234.95 ± 71.88 min, 168.25 ± 61.33 min, and 39.19 ± 9.45 min, respectively. The circulatory arrest and cardiac arrest times were shorter in the graft inversion group than in the conventional group (36.46 ± 7.88 min vs. 42.19 ± 10.17 min, P = 0.001 and 156.21 ± 55.99 min vs. 181.44 ± 64.68 min, P = 0.031, respectively). There were 7 cases of stroke (6.4%) and 5 cases of paraplegia (4.6%). Additionally, 13 patients (11.9%) required temporary continuous renal replacement therapy. Respiratory failure occurred in 19 patients (17.4%). There were no significant differences in postoperative complications between the two groups.ConclusionsThe 4-branched graft inversion technique provides effective and confirmed haemostasis during total aortic arch replacement using the frozen elephant trunk procedure.

Open Repair of Thoracoabdominal Aortic Aneurysms With a Four-branched Graft

A four-branched graft (BG) in thoracoabdominal aortic aneurysm (TAAA) open repair (OR) is especially ideal in four conditions: connective tissue disorder (CTD), dissection, great distance of visceral vessels in the native aorta, and reoperation for visceral patch aneurysm. While increasing the time to visceral vessel revascularization, it decreases the ischemic time of the legs and pelvis, possibly reducing spinal cord injury rates. We report the operative results of a single-center experience.

Surgical strategies in the management of chronic dissection of the thoracoabdominal aorta.

Most operations for dissection of the thoracoabdominal aorta take place in the chronic phase of the disease, because the acutely dissected distal aorta is almost always initially treated non-surgically with aggressive pharmacological anti-impulse therapy. Identifying patients who are no longer responding to medical treatment is the first step in preventing further disease progression and rupture. Symptomatic aneurysms should be promptly repaired. Asymptomatic patients are followed until significant aortic dilation occurs and reaches a threshold of intervention: current guidelines endorse repair once a diameter of 5.5 cm is reached. In patients with heritable thoracic aortic disease (such as Marfan Syndrome), the threshold of intervention is often lowered. Aortic replacement typically centers on the dilatated segment. For all extents of repair, we use passive mild hypothermia, sequential aortic cross-clamping, aggressive reimplantation of intercostal and lumbar arteries, and cold renal perfusion whenever possible. For Crawford extents I and II thoracoabdominal aneurysm repair, we routinely use cerebrospinal fluid drainage, left heart bypass, and selective visceral perfusion. A four-branched graft approach to thoracoabdominal aortic aneurysm repair is frequently used in patients with chronic aortic dissection; this approach facilitates visceral artery perfusion during repair, expedites the distal anastomosis, and prevents subsequent visceral patch aneurysms. Lifelong imaging surveillance is necessary, because the distal aorta often continues to expand; residual aortic dissection commonly remains after repair and may necessitate further repair.

Machine learning for the prediction of acute kidney injury and paraplegia after thoracoabdominal aortic aneurysm repair.

Prediction of acute renal failure (ARF) and paraplegia after thoracoabdominal aortic aneurysm repair (TAAAR) is helpful for decision-making during the postoperative phase. To find a more efficient method for making a prediction, we performed tests on the efficacy of different machine learning predicting models. Perioperative TAAAR data were retrospectively collected from Beijing Anzhen Hospital and Shanghai DeltaHealth Hospital. Operations were conducted under normothermia using a four-branched graft. Four commonly used machine learning classification models (ie, logistic regression, linear and Gaussian kernel support vector machine, and random forest) were chosen to predict ARF and paraplegia separately. The efficacy of the models was validated by five-fold cross-validation. From 2009 to 2017, 212 TAAARs were performed. ARF was identified in 27 patients, and paraplegia was found in 18 patients. Five-fold cross-validation showed that among the four classification models, random forest was the most precise model for predicting ARF, with an average area under the curve (AUC) of 0.89 ± 0.08. Linear support vector machine was the most precise model for predicting paraplegia, with an average AUC of 0.89 ± 0.18. The prediction program has been uploaded to GitHub for open access. Machine learning models can precisely predict ARF and paraplegia during early stages after surgery. This program allows cardiac surgeons to address complications earlier and may help improve the clinical outcomes of TAAAR.

Reconstruction of an isolated left vertebral artery during total aortic arch replacement to preserve cerebral perfusion

We describe a technique of reconstruction of an isolated left vertebral artery (ILVA) in total aortic arch replacement. An octogenarian man, with a distal aortic arch aneurysm and whose cerebral perfusion was dependent on an ILVA, underwent total aortic arch replacement combined with an open stent-grafting technique. The ILVA was reconstructed as follows: a short prosthetic graft was first anastomosed to the ILVA in an end-to-side fashion, and the graft was first used as a route for selective cerebral perfusion to the ILVA. Subsequently, the ILVA was reconstructed by means of interposition between the third branch of the four-branched graft and the graft which was anastomosed to the left axillary artery in an extra-anatomical fashion. The patient experienced no neurologic complications. This method is technically easy and useful for maintaining adequate perfusion of an ILVA during its reconstruction while avoiding direct cannulation to it for selective cerebral perfusion.

IF15. Comparison of Outcomes of Open Repair of Thoracoabdominal Aortic Aneurysms and Dissections in Marfan and Degenerative Patients

We report our series of patient treated with TAAA open repair in patients with Marfan syndrome (MFS). In the period 1993 to 2015, 63 of 736 consecutive TAAA open repairs performed in our center were performed in patients with MFS. In this group, mean age was 43 ± 6.2 years, chronic postdissection aneurysms were reported in 51 patients (80.9%), and urgent procedures were performed in nine patients (14.3%). Left heart bypass and cerebrospinal fluid drainage were instituted in 77.7% and 63.5% of the cases, respectively. Four-branched graft was used in 53 cases (84.1%). Total phrenotomy was performed in 55% of the patients. Renal arteries perfusion was performed with 4°C Ringer's lactated solution in 19 patients, with 4°C Custodiol solution in 44. After propensity-score matching based on baseline clinical, anatomical, and intraoperative variables, we were able to match 54 patients with MFS (MFS group) one-to-one with those who undergoing degenerative TAAA repair (degenerative group). Overall operative time, clamping time, and intraoperative bleeding were significantly increased in the MFS group (318 minutes vs 240 minutes [P = .016], 92 minutes vs 62 minutes [P = .03], and 8050 mL vs 4650 mL [P = .07], respectively). The 30-day mortality in MFS group and in degenerative group was 3.7% and 12.9% respectively (P = .01); paraplegia was 5.5% and 11.1%, respectively (P = .048), and respiratory failure was 7.4.% and 16.6%, respectively (P = .02). Freedom from need of hemodialysis or continuous venovenous hemofiltration was significantly increased in the MFS group (1.8% vs 14.8% P = .003) despite longer total renal ischemic time (58.4 ± 17.3 minutes vs 46.1 ± 16.4 minutes; P = .05). Reintervention rate in MFS group and in degenerative group was 3.7% and 14.8%, respectively (P = .09). TAAA Open repair in MFS patients is an effective option with mortality and neurological complications similar to those reported in degenerative TAAA open repair. Perioperative renal function seems to be more preserved in MFS patients. Careful follow-up is mandatory for the higher risk of reintervention in MFS patients.

Late leakage from four-branch prosthetic graft after total aortic arch repair.

We present two cases with late graft leakage of unknown aetiology after open total aortic arch repair (TAR). Case 1: a 73-year-old woman underwent TAR for arch aneurysm with 24-mm four-branch graft. She had a previous history of pacemaker implantation for sick sinus syndrome and warfarin therapy for atrial fibrillation. Follow-up computed tomography (CT) revealed increased low-density area around the graft 4 years after surgery and blood leakage was shown in delayed-phase CT. Thoracic endovascular aortic repair (TEVAR) was performed to cover the haematic leakage, and shrinkage of the lesion was achieved 1 month after TEVAR. Case 2: a 72-year-old man with diabetes mellitus, hypertension and hyperlipidaemia was admitted to our institute for treatment of aortic arch aneurysm. TAR was successfully performed; however, leakage from the prosthetic graft was noticed by expert radiologists in follow-up delayed-phase CT scan 6 years after surgery. The leakage was resolved 1 month after TEVAR. Although the cause of late leakage was not determined, the slowly expanding haematoma proved to be treatable by additional TEVAR.

Combined total aortic arch replacement associated with aortic valve replacement and subtotal thyroidectomy

The aim of this study is to present a 57-year-old female patient in whom a combined total aortic arch replacement associated with aortic valve replacement and subtotal thyroidectomy was simultaneously performed. The patient was admitted to the Department of Neurology due to isolated seizure of the right upper limb, with progression of the paresis. The symptoms resolved after a few hours. Seven months earlier, the patient suffered from a haemorrhagic stroke in the right hemisphere due to an aneurysm of the distal branch of the callosomarginal artery. The pathology was then treated by embolisation of the aneurysm. During current hospitalisation, diagnostic tests showed goitre, paroxysmal atrial fibrillation, and aortic valve insufficiency. Computed tomography angiography confirmed aortic dissection — Stanford type A, with dissected aortic arch, brachiocephalic trunk, both common carotid arteries, and the left subclavian artery (Figs. 1, 2). After completed diagnostics, the patient was transferred to the Department of Cardiac Surgery for immediate operation. It was decided to perform a combined aortic valve replacement with total aortic arch replacement and subtotal thyroidectomy. Longitudinal skin incisions on the neck were performed to expose both carotid arteries. Median sternotomy was performed. Brachiocephalic trunk and the right atrium were cannulated. Extracorporeal circulation (ECC) was established and the patient was cooled to 28oC. The aorta was clamped, aortotomy was performed, and Calafiore blood cardioplegia was introduced into the coronary ostia. Aortic valve was replaced using a 21-mm bioprosthesis. Proximal anastomosis with a four-branched graft to the ascending aorta was performed. The selective antegrade cerebral perfusion started, and under circulatory arrest the distal part of the graft was anastomosed with the descending aorta above the left subclavian artery, also using a felt strip and Bio-Glue (Fig. 3). Circulation was restored through the graft. The four-branched graft was anastomosed with both common carotid arteries and the right subclavian artery. Due to dissection of the right internal carotid artery, the vessel was separately reconstructed. During reperfusion and rewarming, a subtotal thyroidectomy was performed (Fig. 4). The surgery took 7 h 10 min, ECC-time was 3 h 22 min, aortic cross clamp time was 1 h 57 min, and circulatory arrest time was 30 min. The postoperative period passed uneventfully. The patient, in a haemodynamically and respiratorily stable state, was discharged 12 days after the surgery to the Department of Cardiology for further rehabilitation. The simultaneous surgical procedures can be safely done after meticulous preparation and diagnostics as well as good constipated surgery sequence. It has to be stated, however, that it requires an individual approach in an environment of an experienced surgical team.

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

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

Initial Experience of Modified Four-Branched Graft Technique and Antegrade TEVAR in Acute Type A Aortic Dissection.

We report the initial experience of modified four-branched graft technique for proximal aorta and arch repair, feasibly combined with antegrade thoracic endovascular aortic repair (TEVAR) to extend distal aortic reconstruction in acute type A aortic dissection. From 2011 to 2013, 12 consecutive patients with acute type A aortic dissection were indicated for arch surgery and underwent surgical replacement of proximal aorta, arch replacement or debranching procedure, and concomitant TEVAR for distal aortic repair. A good surgical field was obtained in all patients. No major complications developed but two hospital deaths were attributed to end-organs damage preoperatively. Good and fast remodeling of thoracic descending aorta was demonstrated in 11 patients in postoperative CT imaging and no aneurysmal dilatation of visceral aorta had been observed in 10 patients during follow-up periods. Modified four-branched graft technique facilitated proximal aorta and arch repair, and provided excellent neurological outcome and favorable short-term results. Single-stage operation combined with antegrade TEVAR is feasible and effective to extend the repair down to the descending aorta, and thus achieved good remodeling of thoracic descending aorta.

Bridge Use of Endovascular Repair and Delayed Open Operation for Infected Aneurysm of Aortic Arch

We present the first clinical report of the successful treatment of an infected thoracic aortic arch aneurysm with the use of endovascular repair as a bridge to second-stage open operation. A 70-year-old patient underwent urgent endovascular repair through the right femoral approach because of a diagnosis of sepsis and impending rupture of an infected thoracic aortic arch aneurysm. After 2 weeks of medical treatment, we successfully performed explantation of the stent graft, wide debridement of the surrounding tissue, and in-situ replacement using a rifampicin-bonded four-branched prosthetic graft with omental flap.

Mid-Long-Term Results After Aortic Arch Repair Using a Four-Branched Graft With Antegrade Selective Cerebral Perfusion

The purpose of this study is to evaluate mid-long-term results of aortic arch replacement. Between 1992 and 2012, 263 consecutive patients underwent aortic arch repair in our institution. Follow-up rate was 92%, and 243 patients were enrolled in this study. Two hundred twelve patients (87%) underwent total arch replacement using a four-branched graft with antegrade selective cerebral perfusion. Ninety-nine patients (41%) were operated on for acute aortic dissection. Hospital mortality was 13.2%. The mean follow-up duration was 3.6 ± 3.7 (0-19) years. Late mortality occurred in 38 patients, 4.3 ± 3.2 (0.3-14.1) years after surgery. The survival rates were 85%, 70%, and 50% at one, five, and 10 years. In the acute type A aortic dissection group, survival rate at one and five years was 86% and 79%. In the nonacute type A dissection group, one- and five-year survivals were 85% and 62% (log-rank test: p=0.0027). The causes of late mortality were respiratory failure in five, aortic aneurysm rupture in six, cancer in four, stroke in eight, others in seven, and unknown in eight. Twenty-six patients had another aortic intervention 3.6 ± 6.0 (0.04-19.6) years after arch repair. Seven patients had stroke after discharge 6.5 ± 3.9 (1.9-13.0) years after repair. Mid-long-term results after aortic arch repair with antegrade selective cerebral perfusion were satisfactory. Acute type A aortic dissection did not negatively influence the mid-long-term survival.

Dr. Sun's Procedure for Type A Aortic Dissection: Total Arch Replacement Using Tetrafurcate Graft With Stented Elephant Trunk Implantation.

Sun's procedure is a modified elephant trunk technique that integrates the advantages of open surgical and endovascular repairs as a treatment of type A aortic dissection. It is named after Dr. Li-Zhong Sun and refers to total arch replacement using a four-branched graft with implantation of a special stented endovascular graft. Since its introduction, it has produced excellent early and late clinical outcomes. We present a video of this procedure and make an overview regarding the technical aspects, surgical indications, and clinical outcomes of Sun's procedure.

A Simplified Inversion Technique for the Frozen Elephant Trunk Procedure Using a Four-Branched Graft

During the frozen elephant trunk (FET) procedure using a four-branched graft, making a distal anastomosis between the noninverted proximal graft and the distal stented aorta is quite challenging and takes time. Here, we introduce a simplified inversion technique for the FET procedure that uses a four-branched graft. This technique makes the distal anastomosis easy and secure, which would contribute to decreasing the circulatory arrest and ischemic time.

Alternative Surgical Approach to Treat Aortic Arch Aneurysm after Ascending Aortic Replacement with Hybrid Prosthesis

We present a surgical technique to treat the distal aortic arch in patients who previously underwent ascending aortic replacement using the frozen elephant trunk. After debranching of the epiaortic vessels using a custom-made four-branch graft and systemic cooling, the extracorporeal circulation is interrupted, maintaining antegrade cerebral perfusion through the four-branch prosthesis. Then the "old" Dacron prosthesis, previously implanted for the ascending aortic replacement, is partially incised at its distal end, leaving a margin of prosthesis anastomosed to the native distal aorta, and the E-vita stent-graft is deployed under direct vision. Then the two margins of the "old" Dacron and the new Dacron E-vita prosthesis (Jotec Inc., Hechingen, Germany) are sutured together with one suture line to guarantee sealing and reconstruction of the aorta. This technique presents several advantages: the discrepancy between the graft size and the native aortic diameter is avoided, performing the anastomosis between two prosthetic materials with similar diameters is easier; there is no risk of tears in the diseased native aortic wall and related bleeding; and finally, it is easier to perform the anastomosis at the level of the ascending aorta rather than at the distal arch, especially when the disease of the aorta is extended to the descending segment.

Debranching of the arch in aortic aneurysms

We read with interest the surgical approach of Kondoh et al. [1] for the treatment of the distal arch aneurysm. They performed the elephant trunk procedure with undersized grafts instead of using the frozen elephant trunk technique with 10–20% oversized stent grafts. One month postoperative the residual ‘endoleak’ was 14% in Group 1, and 67% in Group 2. They performed an additional procedure in 77% of these patients. Although 92% of the patients were operated on electively, hospital mortality and cumulative mortality rates were 7.1 and 21.2%, respectively. They performed a two-staged elephant trunk technique in patients with the descending aortic diameter ≥35 mm. In more recent procedures, they started using endovascular techniques in the second stage. The technique of catching the graft with a snare (inserted by the endovascular technique) and pulling it inferiorly is a dangerous procedure that could easily cause a rupture of the fragile aorta, or distal embolism. When compared with the above technique, the frozen elephant trunk procedure or stent graft completion after the first elephant trunk open procedure appears to be safer. Landing a stent graft within the elephant Dacron segment either as a ‘frozen’ technique or at a later time is far more efficient and leads to fewer life-threatening complications [2]. While working at the level of the diseased arch or distal ascending aorta may be technically more demanding, suturing the four-branched arch graft to the sinotubular junction will compromise any future surgical interventions to the heart. In their technique, the distance between the coronary arteries and the arch branches is not sufficient for cross clamping of the aorta in reoperation. In the debranching procedure, suturing the branched graft 3–4 cm above the sinotubular junction will facilitate effective reoperation [3]. In conclusion, it is an interesting study. We thank the authors for sharing their experience. We think it is important to effectively obliterate the full aneurysm as early as possible, rather than wait for thrombosis to occur in a delayed fashion. The elephant trunk procedure combined with the endovascular technique is a safer alternative to the catheter pulling technique described by the authors.

Reply to Ugur et al.

We thank Ugur et al. for taking the time to respond to our study [1, 2]. Although we share their concern about choosing a safe and effective treatment, we draw quite different conclusions. First, we appreciate Ugur et al.’s concerns about the safety of our catheter-pulling technique, but we think they are misplaced. As we described [2], the elephant trunk is inserted into the descending aorta in the open distal condition, which does not require force, and the catching catheter safely retains the elephant trunk in the aortic lumen without rupturing it or causing peripheral thromboembolism, at least among our cases [2]. Following the distal anastomosis, any debris or air is meticulously removed by retrograde perfusion via a small cannula placed in the right femoral artery. Thus, the catheter-pulling technique we used seems both easy and safe [2, 3]. Ugur et al. also asserted that the frozen elephant trunk (FET) procedure is safer than ours, citing a multicentre evaluation of the FET technique [4] to support their statement. We found this puzzling, because the report by Pacini et al. actually showed a higher incidence of almost all postoperative complications with FET, including hospital mortality, bleeding, neurological complications, permanent paraplegia and paraparesis, than we reported, as well as a much longer visceral ischaemic time (75 min) than ours (25 min) [2, 4]. With regards to reoperation, Ugur et al. are correct that the distance between the coronary arteries and the arch branches is insufficient to permit cross-clamping of the aorta. Therefore, for reoperation, the first and second branches of the four-branched arch graft must be cannulated to permit selective anterograde cerebral perfusion, and the aortic cross-clamping must be placed between the second and third branches. Thus, an additional manoeuver is indeed required for reoperation; however, we believe that this difficulty is compensated by the ease and safety of performing the total arch replacement [2]. Finally, we agree with Ugur et al. that thrombo-exclusion of the aneurysm and peri-graft space should be accomplished as early as possible. However, we do not agree with achieving this by placing the distal end of the elephant trunk beyond the eighth vertebral level, because of the associated increased risk of spinal-cord injury [5]. Moreover, Karck and Kamiya recently reported that implantation of a FET is indicated only for patients with extended pathology of the first half of the descending aorta [6], which is effectively the same as our criterion, i.e. using the diameter of the descending aorta at the Th6-8 vertebral level to determine whether to choose the single-elephant trunk or the staged-elephant trunk surgery [2]. Therefore, we continue to believe that our procedure is promising regarding safety, a decreased need for a second-stage operation, and favourable long-term survival, and we disagree with Ugur et al. that the elephant trunk procedure combined with the endovascular technique is safer. Nonetheless, we emphasize that the only empirical resolution of this debate will require the performance of appropriately powered randomized controlled trials.

Invited commentary

To create on-table fenestrated stent grafts requires a perfect knowledge of the technical aspects involved with this technology. The authors have previously written a number of articles on this topic, describing technical aspects and results in elective patients. Now, they present results in 12 acute patients with both complex abdominal and thoracoabdominal aneurysms. The results are such that one might be tempted to start using this method. Nevertheless, readers should understand all the risks involving homemade modifications (eg, exact orientation of the fenestrations in an oversized graft, the use of diameter-reducing ties, and reloading the device). In addition, back-table modification of a graft may compromise its sterility. Is it barely possible to match the safety and precision of a commercial professional organization. I am therefore tempted to say: do not copy this at home! That the article suffers from heterogeneity and that branches may be more forgiving and easier than fenestrations in thoracoabdominal aortic aneurysms (TAAAs), with not all symptomatic or even ruptured TAAAs requiring urgent treatment, does not temper my admiration for the skills and dedication of the authors and their team. Nevertheless, the homemade technique is not here to stay, but merely an incentive for commercial companies to develop off-the-shelf fenestrated and branched grafts. At this moment, with the custom-made fenestrated graft being released in the United States, the Cook (Bloomington, Ind) off-the-shelf four-branched graft has just received European community approval (CE mark). It is likely that a completely endovascular approach for acute TAAAs will compete well with the other available technical options (open, hybrid, and snorkels). In pararenal aneurysms, several off-the-shelf fenestrated devices have recently been made available for use in Europe. Over the years, it has proved very difficult to establish guidelines and minimum requirements before centers were allowed to use fenestrated and branched grafts. With custom-made grafts, however, there was some control, as planning and ordering of the graft involved the manufacturer. With grafts available off-the-shelf, it might become even more difficult to control the process. Using off-the-shelf grafts in less suitable, acute, or elective patients, especially by less experienced operators, will undoubtedly carry a high risk of failure. Controlled distribution of these grafts is therefore mandatory. Interested physicians have to understand the need to invest in these techniques before applying them to their patients. In conclusion, I can only applaud Dr Ricotta et al for their fantastic homemade work. I am eagerly awaiting further commercial developments but also realize the risks involved with these new products. Surgeon-modified fenestrated-branched stent grafts to treat emergently ruptured and symptomatic complex aortic aneurysms in high-risk patientsJournal of Vascular SurgeryVol. 56Issue 6PreviewFenestrated-branched stent grafts have been developed as a minimally invasive, endovascular alternative for the treatment of complex aortic aneurysms in high-risk patients. However, the manufacture of these devices can take as long as 6 to 12 weeks, and therefore, they cannot be used to treat aortic emergencies. We reviewed our experience with surgeon-modified, fenestrated-branched stent grafts (sm-FBSGs) in high-risk patients who presented as emergencies with ruptured or symptomatic complex aortic aneurysms. Full-Text PDF Open Archive

Modified Four-Branched Graft Technique Without Circulatory Arrest and Antegrade Thoracic Endovascular Aortic Repair for Extensive Thoracic Aorta Reconstruction

A modified technique is described, using four-branched graft for proximal aortic repair without the need of deep hypothermic circulatory arrest, and simultaneously using antegrade stent-graft implantation for thoracic endovascular aortic repair of distal aorta in patients with extensive aortic aneurysm, acute type A aortic dissection, and chronic type B dissecting aneurysm. A good surgical field was obtained in 6 patients in this report, and no hospital mortality developed. The modified four-branched graft technique with no circulatory arrest provided good short-term outcome for proximal aorta repair, and the single-stage operation combined with antegrade thoracic endovascular aortic repair is feasible and effective to extend the repair down to the descending aorta.