Anatomical Aortic Arch Repair in Zone 0: Upgrade of the FET Procedure by Endovascular Technology

P0038 

Abstract Submission 

Sven Peterss (1), Nikolaos Tsilimparis (1), Joscha Buech (1), Caroline Radner (1), Linda Grefen (1), Thomas G. Fabry (1), Simon Rutkowski (1), Christian Hagl (1), Maximilian Pichlmaier (1)

(1) LMU University Hospital, Munich, Germany

Sven Peterss    -  Contact Me
LMU University Hospital

Nikolaos Tsilimparis    -  Contact Me
LMU University Hospital

Joscha Buech    -  Contact Me
LMU University Hospital

Caroline Radner    -  Contact Me
LMU University Hospital

Linda Grefen    -  Contact Me
LMU University Hospital

Thomas G. Fabry    -  Contact Me
LMU University Hospital

Simon Rutkowski    -  Contact Me
LMU University Hospital

Christian Hagl    -  Contact Me
LMU University Hospital

Maximilian Pichlmaier    -  Contact Me
LMU University Hospital

Sven Peterss    -  Contact Me
University Hospital Munich

Objective: Total aortic arch replacement using the Frozen Elephant Technique (FET) remains a technically challenging and time-consuming procedure and the reinsertion of the supraaortic vessels occasionally difficult. In 2017, our group published a stent bridging technique to simply the reinsertion and to transpose the distal anastomosis to Zone 2. To move the distal anastomosis yet further to Zone 0, however avoiding any debranching or rerouting techniques, we developed a new custom-made hybrid prosthesis, which employs established endovascular methods to allow anatomical reconstruction of the arch. The prosthesis holds a classical "standard" outer side branch for the brachiocephalic trunk in front of the sewing collar and two inner branches beyond. The latter allow the reconnection of left common carotid and left subclavian artery by placing bridging stents from inside the main graft through the inner branches to the recipient vessel. In 2022, we reported the first-in-man implantation and presented the technique. Here, the first clinical experience and technical challenges are presented.
Methods: Seven patients underwent total arch replacement using the custom-made prosthesis, median age was 56 years (range 42-76). Six patients suffered from acute aortic dissection type-A, one from aortic arch aneurysm with subacute type-B dissection. Median follow-up including CT scan was 833 days (563-1182).
Results: The median graft size (body and stent–a non-tapered design) was 26mm (24-33). The length of the stented portion was 160mm (152-180). Median diameter of the bridging stents to the left common carotid artery and left subclavia artery were 9mm (8-9) and 11mm (10-13), respectively. Circulatory arrest times dropped from 60 minutes (38-97) in a historical SAVSTEB cohort to 37 minutes (23-61).
All patients survived the index procedure and are still alive at follow-up (100% completed). One patient underwent reexploration due to bleeding. No strokes, renal or cardiac complications were observed perioperatively or during follow-up.
The main prosthesis showed 100% technical success. However, two patients required FET extension due to distal progression of disease during follow-up.
Regarding the supraaortic vessel reconnection, two major technical failures were observed. One subclavian stent dislocated during placement unnoticed into the descending aorta and the upper extremity perfusion had to be secondarily secured by a carotid-subclavian bypass. One stent was misplaced into the vertebral artery without clinical consequences. Again, a carotid-subclavian bypass was performed. Two minor issues were observed: one type Ib endoleak in the carotid artery due to a short stent graft and one Ia endoleak due to inadequate ballooning of the stent. Both were solved by endovascular techniques - extension and relining.
Conclusions: Combining endovascular and conventional surgical techniques may improve the overall strategy in open surgery by reducing the HCA time, reducing invasiveness and improving safety. The anatomical reconstruction of the aortic arch from zone 0 is feasible and reproducible and avoids extensive debranching and rerouting techniques. Sutureless attachment of the supraaortic vessels from inside the main graft has now been proven feasible. However, a learning curve and new potential pitfalls have to be overcome. Nevertheless, the custom-made Zone 0 prosthesis felt to be the next logical developmental step for anatomic reconstruction.

Aortic Arch