Head-First Graft Technique in Aortic Arch Replacement

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This video demonstrates a 63-year-old male with a prior type A aortic dissection status post repair, who presented with a residual type B dissection and an aneurysm.  
 
The key steps of the procedure are outlined and presented in the video.  
 
The authors divided the base of the innominate artery with a stapler. The distal end of the head-first graft was sewn to the innominate artery, and the most proximal side arm was connected to the perfusion line. The left common carotid artery was then divided and sewn to the middle side arm. Next, the surgeons cannulated the superior vena cava for retrograde cerebral perfusion. The hybrid frozen elephant trunk (FET) was loaded into position and then deployed. The hybrid FET was sewn to Zone 2, and the lower body was reperfused. The left subclavian artery was revascularized using the distal arm of the hybrid FET. The authors then resected the previous hemiarch graft of the patient, completing the anastomosis of the hybrid FET to the aortic root. Next, the clamp was removed to reperfuse the heart. The head-first graft was then sewn to the hybrid FET to minimize cardiac ischemic time. After separation from cardiopulmonary bypass, the surgeons divided the side arms of both the head-first graft and the hybrid FET. Before closing, the authors ensured that hemostasis was obtained. 
 
The benefits of using a head-first graft are that it can reduce cardiopulmonary bypass, cross-clamp, and circulatory arrest times. It can potentially lower the risk of stroke. The left subclavian artery can be revascularized to the head-first graft or directly onto the hybrid FET, ensuring dual perfusion to the upper body by providing separate sources between the left common carotid artery and the left subclavian artery. This approach ensures that future reintervention is more accessible. The authors have completed more than 120 FET cases using the head-first approach, with a patient population that included 9.6 percent presenting with aneurysms and 16.4 percent presenting with dissections. The patients with dissections were more emergent, and the postoperative stroke rate was recorded at 13.4 percent. 

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