https://orcid.org/0000-0002-0991-3960
Abstract
Secondary root and distal thoraco-abdominal endovascular aortic re-interventions can be challenging after frozen elephant trunk. We obtained from the TERUMO Aortic custom-made platform a Thoraflex graft with a modified disposition of the arch branches that facilitate secondary proximal and distal reinterventions. Here we describe the graft and our first implant.
INTRODUCTION
Aortic pathology is progressive in its nature and aortic reinterventions, proximal on the aortic root and distal on thoraco-abdominal aorta, are often required following a frozen elephant trunk (FET) operation [1]. The available FET grafts were designed to recreate normal aortic arch anatomy with the distal anastomosis performed distal to the left subclavian artery (LSA). However, most aortic surgeons now perform the distal anastomosis more proximally (zones 0, 1 and 2) [2].
With the consequential proximalization of the side branches, access to the aortic root becomes hampered as it requires a very low aortic clamp. Endovascular thoraco-abdominal aorta repairs (ETAR) could also be more difficult as the visceral vessels are arduously cannulated from an upper body access with the double angulation that current FET grafts generate (Fig. 1A–C). Here, we present a new custom-made Thoraflex graft specifically designed to facilitate proximal and distal interventions after FET.
(A) Currently available frozen elephant trunk grafts. (B) The proximal first branch obstacles re-access to root (white arrow); the double angulation prevents a straight antegrade route for wires and catheters from upper body accesses to visceral vessels (red arrows). With T-next configuration (C and D), reaccess to the root is easier as distal aortic clamping is possible and an easy straight antegrade route from upper body access to visceral vessels is provided. (E) Postoperative computed tomography scan.
PATIENT AND METHODS
We report a case of a 74-year-old lady with multiple atherosclerotic thoracic and thoraco-abdominal aneurysms. The preoperative echocardiogram showed a moderate aortic regurgitation. The patient was scheduled for aortic valve replacement plus FET followed by ETAR in a second step.
To facilitate secondary open root and ETAR, we obtained from the TERUMO Aortic custom-made platform a Thoraflex graft with a modified distal and transverse disposition of the arch branches. This would allow for a longer proximal graft segment totally free from other prosthetic structures and more comfortable distal aortic clamping during root reintervention. Additionally, this new arrangement would provide a straight antegrade route for wires destined from un upper access to the visceral vessels with ETAR simplification [3]. We named our graft design T-next, where T stands for ‘THINK’ to patients’ NEXT aortic operations. Technical details are depicted in Fig. 2.
T-next design: From left to right, a single 10-mm branch with 90° angulation for the Innominate artery (IA) used for antegrade catheterization of visceral vessels, a bicurcated branch for the left common carotid artery (LCCA) and left subclavian artery (LSA), an anteflow branch.
At primary FET operation median sternotomy, cardiopulmonary bypass, antegrade selective cerebral perfusion, moderate hypothermia and circulatory arrest to accomplish the distal anastomosis at zone 2 were used. The aortic valve was replaced using a tissue valve. The T-next graft could be easily orientated during implantation while sizing, deployment and arch recontruction techniques remained identical to those employed with the traditional Thoraflex graft (Fig. 1A).
Secondary ETAR was performed 4 weeks afterwards. The right axillary and common iliac arteries were surgically exposed. A 34–34–200-mm Valiant Captivia (Medtronic, USA) endoprosthesis was deployed in overlap to the FET. Secondly, an inner-branched 38–26–21 mm E-nside endograft (Jotec, Germany) was deployed while the coeliac trunk, renal and superior mesenteric arteries were connected to the graft branches using covered stents from the right axillar access (Fig. 1D). The postoperative course was uneventful.
DISCUSSION
Patients often return for reoperative surgery following an FET intervention [1]. Therefore, it is crucial that primary operations on the aortic arch adequately prepare patients for the following procedures. Currently available FET grafts often fail to achieve this goal because distal anastomoses are increasingly being performed in zones 0, 1 and 2 resulting in a very proximal emergence of the arch vessel branches that may hamper proximal root and distal ETAR reinterventions.
Our T-next design modifies the currently available Thoraflex graft in the disposition of its branches for the arch vessels. This design ensures a proximal graft segment totally free from other prosthetic structures, makes sternal reopening less hazardous and facilitates distal aortic clamping. In addition, as demonstrated in our case, it preserves a good bidirectional ‘connection’ for wires and catheters between upper and lower body accesses that, after FET, maintain feasible secondary distal visceral vessels stenting during ETAR (top-down) as well as other diagnostic/interventional procedures on extra/intra-cranial cerebral circulation from the femoral arteries (down-top). Compared to other FET grafts with 1 trifurcating branch, we believe that T-next, with an independent IA branch for distal catheterization, may reduce cerebral complications.
CONCLUSION
We believe that the T-next FET graft, facilitating proximal root and ETAR re-interventions, can be helpful to colleagues that may serve patients like ours. A larger number of implants are warranted to confirm our preliminary favourable experience.
Conflict of interest: none declared.
Reviewer information
European Journal of Cardio-Thoracic Surgery thanks Luca Di Marco, David C. Reineke and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.
