Descending aortic replacement after frozen elephant trunk: graft clamping and true-lumen anastomosis

Second-stage descending aortic replacement after arch replacement with a frozen elephant trunk requires proximal control at a site that is often hostile to cross-clamping. The conventional elephant trunk technique was introduced to avoid cross-clamping the vulnerable proximal aorta; the previously implanted graft, left hanging in the descending aorta, is grasped and clamped directly, and the new graft is sutured to it. This video tutorial demonstrates the manoeuvre in the current era of the frozen, stented elephant trunk. In a patient with a frozen elephant trunk, computed tomography confirmed complete circumferential thrombosis of the false lumen around the stented graft. Through a left thoracotomy the distal aorta was clamped, and the completely thrombosed false lumen was opened without a proximal cross-clamp. The previously implanted stented graft was exposed and clamped directly, providing proximal control without dissecting or cross-clamping the densely adherent native aorta and without damaging the stent. The new graft was anastomosed proximally to the unstented distal cuff, and distally to the true lumen only, avoiding leak into the false lumen and limiting late aortic enlargement. The imaging that makes the approach safe, the step-by-step conduct, and the pitfall of identifying the graft within the walled-off true lumen are described.