A modified turn-up anastomotic technique for total arch replacement: the "frill-necked lizard" configuration

Secure distal anastomosis is the critical determinant of success in total arch replacement (TAR). We aimed to examine the outcomes of a turn-up technique for TAR and introduced a modified turn up method with graft like frill-necked lizard for distal anastomosis, which provides secure anastomosis under excellent visualization, regardless of underlying pathology or the use of a frozen elephant trunk (FET).

We retrospectively evaluated 228 consecutive patients who underwent TAR for 119 thoracic aortic aneurysms (TAA) and 109 acute aortic dissections (AAD) between January 2013 and January 2024. We initially used the turn-up method for distal anastomosis. More recently, we have adopted a modified turn-up method with a frill-necked graft. We evaluated overall surgical outcomes of TAR and performed a comparative analysis between patients with TAA and AAD. Circulatory arrest time during distal anastomosis with the modified turn-up technique was compared with that of the conventional turn-up technique.

For all patients, the operation, cardiopulmonary bypass, aortic cross-clamp, and lower body circulatory arrest times were 376.2±81.7, 229.3±56.1, 148.6±47.1, and 52.4±16.5 minutes. The circulatory arrest times required for distal anastomosis were 53.1±15.9 and 51.6±17.2 minutes in the TAA and AAD groups. The overall 30-day mortality was 3.1%. The permanent neurological dysfunction rate was 5.7%. Spinal cord complications included three cases of paraparesis; there was no case of paraplegia. Kaplan-Meier survival analysis showed an overall 5-year survival rate of 87.6%. Circulatory arrest time was significantly shorter in the modified turn-up group compared with the conventional turn-up group (34.4 ± 9.4 min vs. 53.9 ± 16.1 min, P<0.01).

The turn-up technique provides secure distal anastomosis regardless of the pathology or FET use and the frill-necked graft facilitates distal anastomosis.