Time saving modification of arch replacement in frozen elephant trunk procedure

Objectives: Frozen elephant trunk represents a major surgery requiring a prolonged time of cardioplegic arrest and cerebral protection under hypothermia and selective cerebral perfusion by fixation of the stent graft in arch Zone 3–4. We present our results of a modified arch replacement with regard to the approximation of stent graft fixation proximally and the re-implantation management of the supraaortic vessels. Methods: From 1.2005 to 08.2010 83 patients (age mean±SD 59±12, male 74%) underwent surgery for combined proximal and distal thoracic aortic disease (43 acute aortic dissection (AAD), 23 chronic aortic dissection (CAD), 17 aneurysm (TAA)) using the frozen elephant trunk technique. In 70/83 patients the stent graft was fixed conventionally in Zone 3–4 after complete arch replacement. The modified arch replacement performed in 13/83. Selective cerebral perfusion and hypothermic circulatory arrest was used in all cases. Results: In all 13 modified procedures the left subclavian artery was transected from the arch prior to cross clamp and during cooling. In cardioplegic arrest the arch was opened and the stent graft was placed into the distal aorta under cerebral perfusion and fixed proximally in Zone 1 (1/13) or Zone 2 (12/13). The reimplantation of the head vessels was performed after the proximal aortic anastomosis and during cardiac reperfusion. The re-implantation of left subclavian artery followed during rewarming by end to side (8/13) or side to side (5/13) graft interponat in the proximal aorta. The time of cardioplegic arrest (105±43 versus 145±36, p=0.001), selective cerebral perfusion (53±15 versus 69±19, p=0.005) and hypothermic circulatory arrest (4±6 versus 9±7, p=0.011) was significantly reduced compared to patients with conventional stent graft placement in Zone 3–4. The mortality rate was 8% and 13% after modified and conventional technique, respectively. Conclusion: The modified arch replacement in frozen elephant trunk technique enables a reduction of the intraoperative ischemic times.