Aortic Valve, Ascending Aorta, and Arch Replacement With Debranching of the Supraortic Vessels and Frozen Elephant Trunk

The authors present a case of aortic valve, ascending aorta, and arch replacement, which included debranching of the supra-aortic vessels and a frozen elephant trunk procedure. Additionally, the authors performed an extra-anatomic bypass for the left axillary artery.

The patient’s preoperative computed tomography (CT) angiogram showed an ascending aortic arch aneurysm.

Steps:

1. The authors placed a 6 Fr catheter in the femoral artery using the Seldinger technique. Then, a soft guide wire was placed into the aortic arch under TEE guidance, via transfemoral access.
2. The guide wire was exchanged for a Pig catheter, and an extra stiff guide wire, which was to be used during circulatory arrest for the E-vita OPEN PLUS (Jotec®, Inc., Hechingen, Germany) implantation, was put into the Pig catheter.
3. The right axillary artery was cannulated using Seldinger technique. The aorta was clamped and cold hematic cardioplegia was infused in a retrograde manner.
4. The aneurysmal portion of the ascending aorta and aortic valve were removed.
5. A stentless 27 mm Medtronic Freestyle™ valve was implanted, using 2-0 Ethibond interrupted stitches with subannular pledegets.
6. The coronary ostia of the bioprosthesis were prepared, first the left and then the right ostia.
7. The coronary buttons were reimplanted using a running 4-0 polypropylene suture.
8. A 30 mm Maquet Hemashield Platinum™ vascular prosthesis was prepared.
9. Inclusion Technique was used to perform the proximal anastomosis between the vascular prosthesis and the valve prosthesis and aorta wall, being careful to give the right angle to the prosthesis. The branches of the innominate trunk and left common carotid artery must be tilted toward the superior vena cava.
10. The vascular prosthesis was cannulated with a Medtronic EOPA 24 Fr cannula, and the selective cerebral perfusion cannulae were prepared.
11. The E-vita OPEN PLUS stent graft system no. 36 was prepared. The positioning aid was mounted on the delivery system of the E-vita Open, the tip of the catheter was inserted in the two closed rings, and the open ring was coupled to the grey part of the delivery system.
12. Once the patient temperature reaches 26°C, the team proceeded with the circulatory arrest and the clamping of the innominate trunk. Then, the right carotid artery was perfused through the cannula placed in the right axillary artery (8 ml/kg/min).
13. The guide wire was recovered.
14. Selective antegrade left carotid artery perfusion (5 ml/kg/min) was begun, monitoring that the perfusion pressure is kept above 60 mm Hg.
15. The 36 mm E-vita OPEN PLUS stent graft system was inserted into the descending aorta over a rigid guidewire and deployed with a pullback mechanism. A positioning aid was used for precise placement of the stent graft section. The distal ring marks the transition from stent graft section to vascular graft section and must be kept in place during deployment.
16. The incorporated Dacron graft was drawn out and sutured to the transected distal arch.
17. The distal anastomosis was performed with a continuous 3-0 proline suture between the Hemashield Platinum™ vascular prosthesis, the cuff of the E-vita prosthesis, and the native aortic arch wall.
18. A vacuum vent line was inserted through a branch of the prosthesis to keep the operative area bloodless.
19. The heart and the vascular prosthesis were de-aired and systemic perfusion was antegradely restored through the side branch of the graft.
20. Because of the unfavorable anatomy and friability of the arterial wall, direct left subclavian artery revascularization was not possible. Thus, the authors decided to isolate the left axillary artery and to make an extra-anatomic bypass.
21. The extra-anatomical graft was tunneled into the mediastinum. The proximal anastomosis was performed between the no. 10 branch of the Hemashield Platinum™ vascular prosthesis and the extra-anatomic vascular prosthesis. Finally, the authors closed the origin of the left subclavian artery with a direct suture.
22. The left carotid artery debranching used the no. 8 branch of the Hemashield Platinum™ vascular prosthesis and a continuous polypropylene 5-0 suture. Selective antegrade perfusion of the left carotid artery was suspended.
23. The innominate trunk debranching was performed with the no. 10 branch of the Hemashield Platinum™ vascular prosthesis, a continuous polypropylene 4-0 suture, and the interposition of a layer of Teflon felt.
24. Patient rewarming was begun. The unused branches of the vascular prosthesis were ligated twice and cut, and the stump was sutured with a continuous 4-0 polypropylene suture.

Follow-up CT angiogram taken after three months showed normal patency of the branches of the innominate trunk, left carotid artery, and extra-anatomic bypass for the left axillary artery.