Reverse insertion of displaced JOTEC prosthesis in the frozen elephant trunk procedure: How to do it

We have observed several cases in which the JOTEC-hybridprosthesis graft used in the frozen elephant trunk procedure dislodged during the operation and was out of reach distally in the aorta. The difficulty consists in maintaining an endovascular approach while recovering the graft. We developed a technique which describes how to recover a JOTEC graft via an additional incision made in the abdominal aorta in the case of a 78 year old male patient with an acute type-A-aortic dissection in which graft dislodgement occurred. The abdominal cavity is accessed using a transdiaphragmatic approach on the right side of the descending aorta. The descending aorta is dissected and the graft is located in the abdominal aorta. An incision is made below the suspected location of the graft so that the graft extension can be reached using a forceps. The graft is extended upwards until it can be reached through the original incision and connected to the proximal prosthesis. We intend to increase awareness for this known complication and to provide surgeons with a safe technique with which the endovascular approach may be preserved in the case of graft-dislodgement. The transdiaphragmatic approach allows access to the descending and abdominal aorta without the need for increasing the size of the thoracal incision. To our knowledge no other article on the treatment of this known surgical complication has been published up to date.