Trunk Surgery Research Articles

Trunk Surgery as a Tool to Reduce Foliar Symptoms in Diseases of the Esca Complex and Its Influence on Vine Wood Microbiota.

In the last few years, trunk surgery has gained increasing attention as a method to reduce foliar symptoms typical of some of the Esca complex diseases. The technique relies on the mechanical removal of decayed wood by a chainsaw. A study on a 14-year-old Cabernet Sauvignon vineyard was carried out to validate the efficacy of trunk surgery and explore possible explanations behind it. Three levels of treatment were applied to three of the most characteristic symptoms associated with some diseases of the Esca complex, such as leaf stripe symptoms (LS), wilted shoots (WS) and apoplexy (APP). The most promising results were obtained by complete trunk surgery, where the larger decay removal allowed lower symptom re-expression. According to the wood types analyzed (decay, medium and sound wood), different changes in microbiota were observed. Alpha-diversity generally decreased for bacteria and increased for fungi. More specifically, main changes were observed for Fomitiporia mediterranea abundance that decreased considerably after trunk surgery. A possible explanation for LS symptom reduction after trunk surgery could be the microbiota shifting caused by the technique itself affecting a microbic-shared biochemical pathway involved in symptom expression.

The zone 2 concept and distal stent graft positioning in TH 2-3 are associated with high rates of secondary aortic interventions in frozen elephant trunk surgery.

The goal of this study was to investigate the association between the localization of the distal anastomosis (zone 2/3), the stent graft length (100-160 mm), the position of the distal end of the hybrid prosthesis and the need for secondary aortic intervention (SAI) in acute and chronic thoracic aortic disease after the frozen elephant trunk procedure. From 2009 through 2020, a total of 232 patients (137 men; mean age, 61.7 ± 13.8 years) were treated with the frozen elephant trunk procedure. The main indications were acute aortic dissection type A (n = 106, 46%), chronic aortic dissection type A (n = 52, 22%) and degenerative thoracic aortic aneurysm (n = 74, 32%). The rate of SAI was significantly higher when we performed a distal anastomosis in zone 2 rather than in zone 3, whereas the rate of SAI was less frequent if the distal positioning of the hybrid prosthesis was below TH 4-5. Combining the zone 2 concept and the short stent graft length (100 mm) was associated with a significantly higher rate of SAIs. Patients with a distal anastomosis in zone 2 were significantly less likely to have a recurrent laryngeal nerve injury (P < 0.001). However, no association between a specific arch zone of a distal anastomosis and the occurrence of spinal cord injury was observed. Rates of SAIs are highest in patients who were treated with a distal anastomosis in zone 2 and a short stent graft (100 mm) with the distal end of the hybrid prosthesis at vertebral level TH 2-3.

Interstage mortality in two‐stage elephant trunk surgery

Diffuse mega-aorta is challenging. Prior studies have raised concerns regarding the safety of the open two-stage elephant trunk (ET) approach for extensive thoracic aortic aneurysm (TAA), specifically in regard to interstage mortality. This study evaluates the safety of the two-stage ET approach for management of extensive TAA. Between 2003 and 2018, 152 patients underwent a Stage I ET procedure by a single surgeon (mean age 64.5 ± 14.8). Second stage ET procedure was planned in 60 patients (39.4%) and to-date has been performed in 54 patients (90%). (in the remaining patients, the ET was prophylactic for the long-term, with no plan for near-term utilization). In-hospital mortality after the Stage I procedure was 3.3% (5/152). In patients planned for Stage II, the median interstage interval was 5 weeks (range: 0-14). Of the remaining six patients with planned, but uncompleted Stage II procedures, five patients expired from various causes in the interval period (interstage mortality of 8.3%). There were no cases of aortic rupture in the interstage interval. Stage II was completed in 58 patients (including four unplanned) with a 30-day mortality of 10.3% (6/58). Seven patients developed strokes after Stage II (12%), and three patients (5.1%) developed paraplegia. The overall mortality, including Stage I, interstage interval, and Stage II was 18.6%. This substantial cumulative mortality for the open two-staged ET approach for the treatment of extensive TAA appears commensurate with the severity of the widespread aortic disease in this patient group. Fear of interstage rupture should not preclude the aggressive Two-Stage approach to the management of extensive TAA.

Efficacy of Erector Spinae Plane Block after Trunk Surgery: A Stratified Randomized Observer-Blinded Comparative Study

Efficacy of Erector Spinae Plane Block after Trunk Surgery: A Stratified Randomized Observer-Blinded Comparative Study

The frozen elephant trunk technique in an emergency: THORAFLEX French National Registry offers new insights.

Our goal was to study the immediate outcome after an emergency frozen elephant trunk procedure with a Thoraflex™ Hybrid prosthesis (THP) in patients included in the EPI-Flex national registry and operated on in 21 French centres. All patients operated on in France between April 2016 and April 2019 for acute aortic syndromes and who had an frozen elephant trunk procedure with a THP were included in the study. The main end point was in-hospital mortality. The secondary end point was neuromorbidity, including paraplegia. The evolution of the main end point was monitored using a variable life-adjusted display graph with cumulative sum derivatives in order to stop inclusions in case the observed mortality became out of range compared to an expected mortality between 15% and 20%. Enrolment ended on the scheduled date and included 109 patients. Most cases (54%) were performed at 3 centres, where more than 10 THP each were implanted (10-26). The observed mortality in the large-volume centres (22%) was comparable to that observed in the low-volume centres (20%). The individually risk-adjusted cumulative sum revealed that observed in-hospital mortality was statistically in line with that predicted by the log EuroSCORE. Analysis of the secondary end point revealed 8% cases of paraplegia, all of which appeared after treatment of the thoracic type A aortic dissection. In France, THP for emergency frozen elephant trunk surgery outside high-volume centres did not result in excessive in-hospital deaths. However, a word of caution must be expressed regarding the prevention of medullar ischaemia even in emergency aortic surgery.

Normothermic frozen elephant trunk surgery without circulatory arrest: how we do it in Ancona

Normothermic frozen elephant trunk surgery without circulatory arrest: how we do it in Ancona

First experience with a ROTEM-enhanced transfusion algorithm in patients undergoing aortic arch replacement with frozen elephant trunk technique. A theranostic approach to patient blood management

Study objectiveTo assess the effect of a rotational thromboelastometry (ROTEM)-enhanced transfusion algorithm with hemostatic agents on allogenic blood transfusion in patients undergoing frozen elephant trunk (FET) surgery. DesignRetrospective observational study conducted in a tertiary-care center. SettingA tertiary care referral center for cardiac surgery. PatientsAll patients undergoing elective FET were included in the study. InterventionUntil 2016, a protocol based on estimated blood losses and conventional coagulation tests was used. After, a ROTEM-enhanced transfusion protocol was adopted. MeasurementsThe transfusion rate of each blood component was observed and reported. MethodsRetrospective, observational study. Main resultsOut of 40 consecutive patients, 19 underwent FET surgery with a conventional transfusion approach and 21 with a ROTEM-enhanced transfusion strategy. Considering the overall transfusion rate, the administration of fresh frozen plasma and platelets was significantly lower in the ROTEM compared to conventional group (1000 [0–2500] vs 0 [0–875] ml, p = 0.015 and 1 [1, 2] vs 0 [0–1], p = 0.016, respectively).ROTEM algorithm allowed to decrease the number of patients who required plasma and platelets transfusion of 31%. Furthermore, a 40% reduction in overall allogenic blood products was observed. Number of red blood cells administered, percentage of patients transfused with red blood cells, blood losses, reoperation for bleeding and mortality did not significantly differ between the two groups. At the multiple linear regression analysis only ROTEM algorithm was associated with a significant decrease in the number of plasma and platelets units administered intraoperatively, at 24 h, at the ICU discharge and overall. ROTEM algorithm allowed to save 1435 ml of plasma, 0.91 unit of platelets and overall transfusion cost of the 21% per patient. ConclusionsA ROTEM-enhanced transfusion strategy halved intraoperative transfusion in the setting of FET. Further studies are needed to confirm the magnitude of our findings on clinically relevant endpoints.

Abstract P188: Electrical Stimulation of Sub-Diaphragmatic Vagal Trunk Alleviates Hypertension in the SHR

Introduction: The vagus facilitates a bidirectional gut-brain communication. Low vagal tone is shown in conditions marked by inflammation and dysbiosis, including hypertension (HTN). However, the role of gut-projecting vagal nerve branches in blood pressure (BP) control is unexplored. Supplementing the potentially impaired gut vagal tone using electrical vagal nerve stimulation (vns) may restore homeostasis of the microbiota-gut-brain axis in HTN. Methods: Male 8 week-old Wistar-Kyoto (WKY, N=6) and spontaneously hypertensive rats (SHR, N=10) were used. Rats were implanted with radiotelemetric BP transducers. WKY rats received either a unilateral surgical vagotomy of the ventral sub-diaphragmatic vagal trunk (vgnx, N=3) or sham surgery (SHAM, N=3). SHR were implanted with either a silicone cuff electrode (500μm, Microprobes for Life Sciences, Gaithersburg, MD) (vns, N=5) or a sham cuff (SHAM, N=5) on same vagal trunk. SHR were connected to an IZ2H current controlled stimulus generator (Tucker-Davis Technologies, Alachua, FL), and subjected to biphasic, 600μA, 0.5s/phase, 25Hz vns for 10 minutes per session, three sessions per day, 5 days per week. 24-hour BP recordings were made once per week for seven weeks in all rats. Relative abundance of gut bacterial phyla ( Firmicutes, Bacteriodetes, Actinobacteria ) was determined in fecal DNA of all rats using qPCR. Results: Compared with SHAM, WKY vgnx showed a significant elevation in systolic BP (SBP) at week 7 post-vgnx (WKY SHAM: 148±4 mm Hg vs. WKY vgnx: 177±4 mm Hg; p &lt;0.05). After 7 weeks of vns, SHR STIM group exhibited a significant dampening in SBP rise from baseline (SHR SHAM: ΔSBP=44±5 mm Hg vs. SHR vns: 22±3 mm Hg; p &lt;0.05) and in mean BP (MBP) rise from baseline (SHR SHAM: ΔMBP=38±4 mm Hg vs. SHR vns: 14±3 mm Hg; p &lt;0.05) compared to SHAM. No difference was observed in relative abundance of major bacterial phyla between the WKY vgnx and SHR vns rats and their respective controls. Conclusions: Bioelectric restoration of gut vagal tone is beneficial in restitution of neural gut-brain axis in control of BP in HTN. Considering no changes were observed in major gut bacterial phyla following WKY vgnx and SHR vns, the observed BP responses may be due to perturbations in gut vagal afferent rather than efferent signaling.

Air-fluidized therapy in the treatment of severe burns: A retrospective study from a burn intensive care unit in Austria

IntroductionAir-fluidized therapy (AFT) has long been used in the treatment of severe burns. In patients with extensive burns involving the posterior trunk, we aim to keep affected posterior areas dry and to postpone their treatment, initially applying available split-thickness skin grafts in functionally more important regions. We retrospectively assessed the impact of AFT on the survival of patients treated in the burn intensive care unit (ICU) of the Medical University of Vienna, Austria, between 2003 and 2016. MethodsThis retrospective single-center study included patients aged ≥18 years with burned total body surface area (TBSA) ≥20% and IIb–III° thermal injuries on the posterior trunk who received AFT. Survival rates were compared with those predicted by the abbreviated burn severity index (ABSI). Demographic, clinical, and surgical data were analyzed. ResultsSeventy-five of 110 patients with posterior trunk burns received AFT. Their survival rate exceeded that predicted by the ABSI score (mean ABSI, 10.0 ± 2.0; 73.3% (95% CI: 62-83%) survival rate vs. 20-40% predicted; p < 0.0001); no such difference was observed in the non-AFT group (mean, 8.8 ± 1.9; 65.7% (95% CI: 48-81%) survival rate vs. 50-70% predicted). Patients receiving AFT had significantly greater TBSA (median, 50% (35–60) vs. 30% (25–45) and longer ICU stays (median, 63 (36–92) vs. 18 (9–52) days; both p < 0.0001). Fifty-one (68.0%) patients in the AFT group and 26 (74.3%) patients in the non-AFT group underwent posterior trunk surgery (p = 0.66) a median of 16 (10–26) and 5 (2.5–9.5) days, respectively, after admission (p < 0.0001). ConclusionsPatients receiving AFT had significantly better survival than predicted by ABSI score in contrast to patients not receiving AFT although burn injuries in this group were more severe (greater TBSA, higher ABSI). As intensive care was similar in these groups aside from AFT, the better survival could be attributed to this additional therapy.

Hybrid Off-pump Second-Stage Aortic Arch Repair after Type A Dissection.

Ascending aorta or hemi-arch repair are common in the acute phase of type A dissection. Postdissection aneurysms can develop with antegrade perfusion of the false lumen in the dissected aortic arch and require reoperation. From 2012 to 2018, we reoperated nine patients with postdissection aneurysms using a hybrid technique without cardiopulmonary bypass. The patients had a EuroSCORE II of 13% and a logistic EuroSCORE I of 45% and were not candidates for frozen elephant trunk surgery. The median interval since the acute ascending repair was 184 (92; 528) days. All patients were treated by median resternotomy, ascending to carotid bypass on a partially clamped ascending graft, and transfemoral endovascular repair with a Relay NBS (nonbare stent) or conformable Gore C-TAG stent graft. Technical success was achieved in all cases. Mean follow-up was 405 (220; 672) days. There was no disabling stroke, endoleak, paraplegia, in-hospital, or late mortality. In all patients, the false lumen was completely thrombosed at the aortic arch level with a median aneurysm shrinkage of 13 mm in the distal arch. There was no bird beak or stent graft migration. Distal stent-induced new entry was observed in one case. Reinterventions were not necessary due to diameter stability. Complete debranching with transfemoral thoracic endovascular aneurysm repair showed encouraging results in patients with relevant comorbidities. The used stent grafts performed well in the mid-term follow-up period with no endoleaks or migration.

494 - The French National Registry (N.O.E.) of elective frozen elephant trunk surgery using the Evita Open Plus: early and mid-term outcomes

494 - The French National Registry (N.O.E.) of elective frozen elephant trunk surgery using the Evita Open Plus: early and mid-term outcomes

Left subclavian artery rerouting and selective perfusion management in frozen elephant trunk surgery

Introduction: The frozen elephant trunk (FET) technique enables combined aortic arch and descending aortic repair. We report our experience with a modified arch replacement technique by rerouting of the left subclavian artery (LSA) and fixation of the FET in Zone 2 or proximally under selective perfusion of all three arch arteries and the downstream aorta. Material and methods: From January 2005 to December 2014, 78 of 173 patients operated with the FET technique underwent rerouting of the LSA. Rerouting was performed as aortic-subclavian, aorto-axillary or carotid-subclavia bypass. Hypothermic selective antegrade cerebral perfusion was established for cerebral protection. A separate cardiopulmonary bypass circuit was added for selective LSA and downstream aorta perfusion during the arch repair. Results: In-hospital mortality, stroke and paraplegia rates were 10%, 8% and 2.5%, respectively. LSA rerouting enabled total arch repair in <60 minutes of selective cerebral perfusion (mean 56 ± 15). No recurrent nerve palsy occurred. The selective perfusion of the downstream aorta led to the reduction of the distal hypothermic circulatory arrest time close to 30 minutes (p < 0.0001). Discussion: LSA rerouting facilitates arch aortic repair by FET surgery. The selective perfusion of all arch arteries and the downstream aorta during open arch repair reduces the ischemic times and may improve organ protection.

Facilitated Frozen Elephant Trunk Surgery by Zone 2 Anastomosis

Objectives: The Frozen Elephant Trunk (FET) technique is used for combined aortic arch replacement and descending aortic repair in extent thoracic aortic disease. The procedure is associated with prolonged ischemic times making the treatment not suitable for every patient. The study presents a single center experience by moving the distal anastomosis from the distal arch (Zone 3) to mid arch portion (Zone 2).

Conventional versus frozen elephant trunk surgery for extensive disease of the thoracic aorta

To compare early and mid-term outcomes after repair of extensive aneurysm of the thoracic aorta using the conventional elephant trunk or frozen elephant trunk (FET) procedures. Fifty-seven patients with extensive thoracic aneurysmal disease were treated using elephant trunk (n = 36) or FET (n = 21) procedures. Patients with aortic dissection, descending thoracic aorta (DTA) diameter less than 40 mm, and thoracoabdominal aneurysms were excluded from the analysis, as were those who did not undergo antegrade selective cerebral perfusion during circulatory arrest. Short-term and mid-term outcomes were compared according to elephant trunk/FET surgical management. Preoperative and intraoperative variables were similar in the two groups, except for a higher incidence of female sex, coronary artery disease and associated procedures in elephant trunk patients. Hospital mortality (elephant trunk: 13.9% versus FET: 4.8%; P = 0.2), permanent neurologic dysfunction (elephant trunk: 5.7% versus FET: 9.5%; P = 0.4) and paraplegia (elephant trunk: 2.9% versus FET: 4.8%; P = 0.6) rates were similar in the two groups. Follow-up was 100% complete. In the elephant trunk group, 68.4% of patients did not undergo a second-stage procedure during follow-up for a variety of reasons. Of these patients, the DTA diameter was greater than 51 mm in 72.2% and two (6.7%) died due to aortic rupture while awaiting stage-two intervention. Endovascular second-stage procedures were successfully performed in all FET patients with residual DTA aneurysmal disease (n = 3), whereas nine of 11 elephant trunk patients who returned for second-stage procedures required conventional surgical replacement through a lateral thoracotomy. Kaplan-Meier estimate of 4-year survival was 75.8 ± 7.6 and 72.8 ± 10.6 in elephant trunk and FET patients, respectively (log-rank P = 0.8). In patients with extensive aneurysmal disease of thoracic aorta, elephant trunk and FET procedures seem to be associated with similar satisfactory early and mid-term outcomes. The FET approach leads to single-stage treatment of all aortic disease in most patients, and facilitates endovascular second-stage treatment in patients with residual DTA disease. The elephant trunk staged-approach appears to leave a considerable percentage of patients at risk for adverse aortic events.

Frozen elephant trunk surgery in acute aortic dissection

Acute aortic dissection is a catastrophic condition, for which emergency surgery is the mainstay of therapy. In approximately 70% of patients who survive surgery, a dissected distal aorta remains, posing a risk of late aneurysmal degeneration, rupture, and malperfusion, and secondary extensive interventions are often required. In order to improve the long-term prognosis, a more extensive intervention, the frozen elephant trunk (FET) procedure, has been introduced. This involves the simultaneous replacement of the aortic arch and antegrade stenting of the descending thoracic aorta (DTA). Although FET is assumed to produce total thoracic aortic remodeling by inducing both coverage of secondary entry tears located in the proximal DTA and obliteration of the false lumen at the proximal DTA, its role in patients with acute dissection remains controversial mostly because of its technical complexity and increased risk of paraplegia. Data available in literature show that, after FET interventions, hospital death, stroke, and spinal cord injury occur in 10.0%, 4.8%, and 4.3% of patients with acute dissection, respectively. Available long-term data are sparse but suggest that aortic remodeling with partial or complete thrombosis of the persistent false lumen can be expected in approximately 90% of cases. The FET technique is a promising approach in patients with acute dissection. Solid long-term data are warranted to validate the assumed short- and long-term benefits, but we believe that thoughtful patient selection criteria remain crucial.

Frozen elephant trunk surgery in type B aortic dissection.

The frozen elephant trunk (FET) technique combines surgical replacement of the aortic arch with simultaneous stenting of the descending thoracic aorta. This approach has been rarely indicated in patients with type B aortic dissection (TBAD). We herein report on our experience with FET surgery in selected TBAD patients.

Role of regional anesthesia in the enhanced recovery after surgery program

The concept of ‘‘enhanced recovery after surgery’’ (ERAS) or ‘‘fast-track surgery’’ using multimodal perioperative care programs was introduced by Kehlet [1] in 1997 and has been evaluated in numerous prospective trials over the past decade. Evidence-based guidelines have been established, particularly for colorectal surgery [2, 3]. The aim of this new concept is to facilitate shortening of the hospital stay and the rapid resumption of normal activities. Evidence-based ERAS items include standard anesthetic protocols, perioperative fluid management, and postoperative analgesia, which are in large part responsible for the role of the anesthesiologist as a key element affecting the outcome of surgery [1]. Among these factors, regional anesthesia used in addition to general anesthesia not only achieves adequate analgesia but also reduces the need for postoperative intravenous opiates and ameliorates the stress response, reducing insulin resistance for example [4]. Therefore, the use of regional anesthesia techniques potentially supports the ERAS concept in different types of surgeries [5]. For example, thoracic epidural analgesia (TEA) is an optimal established analgesia element in the ERAS protocol for open laparotomy [2, 3]. However, few regional anesthesia techniques, including transversus abdominis plane (TAP) block [6], the infiltration of local anesthetic into the surgical incision [7], and an intravenous infusion of local anesthetics [8], are recommended at a middle-grade evidence level [1]. The aim of this article is to clarify the potential of regional blocks as a primary item of multimodal analgesia in the ERAS protocol for trunk surgery.

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.

Editorial Comment: Frozen elephant trunk surgery: where do we go from here?

As reported, 30-day mortality was 16.4%, and permanent neurological dysfunction and paraplegia occurred in 15.2% and 8.8% of patients respectively. Focusing on the frozen elephant trunk patients, Dr Leontyev reported a 30-day mortality of 8.7%, with disappointing rates of permanent neurological deficit and paraplegia of 13% and 21.7% respectively. It should be recalled that such results, and in particular the adverse neurological outcomes, strongly deviate from those reported from the International E-vita Registry which revealed 7% spinal cord injury, with 6% PND. I share your conclusions that neurological outcome can be significantly improved by keeping core temperature between 24–26 degrees centigrade and the duration of circulatory arrest below 35 min. Second, the elephant trunk and frozen elephant trunk patients were remarkably different and therefore hardly comparable. Elephant trunk patients had more acute aortic dissection and more thoraco-abdominal aortic aneurysms. Furthermore, more profound levels of hypothermia were used in elephant trunk patients as compared to FET patients. Thus, comparative short- and mid-term results and the surgical implications should be considered with great caution. Dr Leontyev: I think the comparison between the two groups, the conventional and the frozen elephant trunk technique, is indeed very important and showed that frozen elephant trunk implantation may be associated with a significantly increased rate of neurological complications. And in my opinion, it is actually the only way to show all the options for treating patients with extensive thoracic aortic disease. This is the reason I do not completely agree with you that it isn’t possible or appropriate to compare the two patient groups.

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.