P022. A Simplified Delivery Frozen Elephant Trunk: A New Approach to Reduce Circulatory Arrest and Allows Hybrid Arch Surgery without Cooling.

Sheraton Times Square 

Objective: Acute type A aortic dissection is a life-threatening cardiovascular emergency and remains a challenge in cardiac surgery with immediate and late complications. The Elephant Trunk technique was developed as a 1-stage repair of the aortic arch and descending aorta and evolved into the Frozen Elephant Trunk (FET), which promotes early thrombosis of the false lumen and positive remodeling of the aorta in 90% of dissection patients . FET, in turn, has benefited from numerous modifications and simplifications as well as incremental improvements in devices. However, most patients still require hypothermic circulatory arrest (HCA) of 40-60 min duration. Many postoperative complications are-directly or indirectly related-to hypothermia. In order to avoid the disadvantages of hypothermia, we propose a simplified delivery FET technique (SD-FET) that is characterized by FEt proximalisation in aortic arch zone 0 (or 1) with a very short curculatory arrest of the lower body, allowing normothermia.
Case video summary: The SD-FET surgical technique essentially involves the placement of two surgical sealing tourniquets. Operation is performed through median sternotomy. Right axillary canulation for arterial reinjection and atriocaval for venous drainage. The supra aortic vessels were put on tourniquet. During the dissection and release of the aortic arch, it is important not to dissect the arch extensively to keep the attachment tissue, especially posteriorly, for the effectiveness of the "sealing tourniquets". The key point of the technique is the placement of these two tourniquets with a blunt dissector around the aortic arch between the innominate artery and the left common carotid artery. The preparation of the prosthesis must be imperatively done before the start of the CA. The Innominate artery is disconnected, and Circulatory arrest is initiated, the cross clamp is removed. The 3 U-stitches are passed through the aorta (to improve the apposition between the aortic tissue and the sewing collar). Insertion of the thoraflex and 3 U stitches passage in the collar. Arterial line reconnection and CPB is restarted via fourth branch at full flow to expand the stent. The two sealing tourniquets are gradually tightened on the aortic arch facing the stent until a zone 0 or 1 seal is achieved. Tourniquets should be tightened gently under the pressure of the antegrade arterial blood flow of the cardiopulmonary bypass (CPB). Complete apposition of the stent to the aortic wall in the tourniquets area allows for a near complete seal. Distal anastomosis could then be performed on a loaded aorta in normothermia.
Conclusion: SD-FET significantly reduces circulatory arrest time and allows the FET procedure to be carried out in moderate hypothermia-and or even without cooling with experience and mastery of the technique. SD-FET is feasible, reproducible, and safe and is associated with a lower occurrence of death and/or neurological events, even in patients requiring combined root surgery.

Authors
Guillaume Guimbretiere (1), charles-henri david (2), Sébastien Gonthier (3), Antoine Buschiazzo (4), Thibaut Schoell (5), Blandine Morel (6), Eric braunberger (7), Nicolas Bonnet (8), Jean Christian Roussel (9), Thomas Sénage (10)
Institutions
(1) N/A, N/A, (2) Cardio-thoracic and vascular surgery unit, CHU Nantes, nantes, NA, (3) Department of Thoracic and Cardiovascular Surgery, Univsersity hospital Felix Guyon, Saint-Denis de la Réunion, France, (4) L'institut du thorax, NANTES, NA, (5) Centre cardiologique du Nord, Saint-Denis, NA, (6) L’Institut du Thorax, Cardiac and Vascular surgery department, Nantes, NA, (7) CHU Felix Guyon, Saint-Denis, NA, (8) Centre Cardiologique du Nord, Paris, France, (9) Nantes Hospital University, Nantes, France, (10) CHU Nantes, Nantes, NA

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