Frozen elephant trunk technique in redo aortic arch surgery: a step-by-step approach

Frozen elephant trunk (FET) is an established treatment modality for complex aortic arch and proximal descending aortic pathologies. While patients with limited life expectancy are more frequently considered for endovascular treatment options, the FET remains a sustainable platform, especially for younger post-dissection and heritable thoracic aortic disease (HTAD) patients. These patients frequently have undergone previous transsternal operations. A substantial portion require concomitant aortic root or other cardiac procedures. In this manuscript we describe our technique of redo valve sparing aortic root replacement (VSARR) and total aortic arch repair with FET implantation. Our technique combines four main technical aspects: (I) central arterial cannulation is our first option with axillary access being a secondary alternative. Femoral cannulation is only used in bail-out situations or in combination with upper body arterial access. (II) We prefer to revascularize the left subclavian artery (LSA) within the chest during the same procedure. Many alternative options exist for specific anatomical situations. Ideally, the LSA revascularization technique should not add any hypothermic circulatory arrest (HCA) time to the procedure. (III) We liberally address concomitant cardiac pathologies during the same procedure. To avoid long cardiac ischemia times in these complex cases, we employ non-cardioplegic myocardial perfusion during aortic arch repairs where ischemia times of >120 min are anticipated. (IV) During aortic arch preparation we use temporary "flush" retrograde cerebral perfusion (RCP) to reduce the risk of embolization to the supraaortic arteries. After aortic arch preparation bilateral or trilateral selective antegrade cerebral perfusion (SACP) is routinely initiated. The technique allows complex combined cardiac and aortic arch operations to be performed in a standardized and controlled surgical environment. FET implantation will remain an important open surgical tool in the armamentarium of complex aortic arch repair. Creating durable surgical results and minimizing surgical risks have to be the primary goals regarding surgical management.