Simplified Technique for Aortic Arch Replacement in Patients at High Risk for Frozen Elephant Trunk

Surgical approach of multisegmental pathology of the thoracic aorta, namely aortic arch / descending aorta is challenging. The Frozen Elephant Trunk (FET) has good results, with acceptable risk. However, in the subgroup of patients (pts) older than 75 years and with important comorbidities, the surgical risk is very high.

Review short-term results of this original, simplified and potentially hybrid technique developed in our Department for this subgroup of patients.

From January 2016 to September 2017, 10 pts were operated with this technique - mean age 70.2 ± 15.3 years, 7 males. The diagnoses were: 6 pts with aneurysmal disease and 4 pts with aortic dissection. Four pts had previous cardiac surgery. The surgical concept consists of 3 key points: 1) Use of a patient-tailored graft, built in a back-table, to replace the ascending aorta and arch, with side-branches proximally anastomosed to reroute the supra-aortic vessels, allowing a proximal, long Landing Zone for eventual TEVAR. 2) Debranching of the supra-aortic vessels. 3) Maintain bilateral anterograde selective cerebral perfusion. All pts were operated on cardiopulmonary bypass (CPB) with a period of hypothermic (24oC) cardiocirculatory arrest for the open distal anastomosis. Preservation of the left subclavian artery depended on paraplegia risk and was individually assessed preoperatively. In a second stage, a TEVAR was electively deployed in 2 patients. All patients were followed in our clinic and imaging clinic at 6 months and annually after surgery.

Mean CPB, aortic cross clamping and visceral ischemia were, respectively, 196, 120 and 44 minutes. One pt died in- hospital due to bowel ischemia. Four pts had respiratory complications requiring prolonged ventilation. The mean ICU and hospital stay was, respectively, 7,8 and 23,6 days. The mean follow-up was 15.2 months and three pts died during this follow-up. One pt was re-hospitalized with deep sternal wound infection. Of the survivors, one had a stroke at 6 months postoperatively and the remainder are asymptomatic. The postoperative period of the 2 pts submitted to TEVAR was uneventful; to date, they remain surgically stable, without needing re-intervention.

The technique is effective and avoids the burden of FET. The short-term results are encouraging but, in the long-term, they should be evaluated to determine their role among arch interventions, specially their value in relation to recent pure endovascular techniques with fenestrated or branched endoprosthesis. Long ICU and hospital stay points towards the implementation of measures and protocols to improve them.