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Safe Cerebral Protection: Frozen Elephant Trunk Procedure

Friday, May 3, 2024

To begin, the innominate artery was cannulated with a 14 or 16 Fr pediatric cannula. A separate circuit was used to perfuse the brain. It was given one liter per minute of perfusion at 20 °C while the rest of the body had a second circuit, which was kept at 34 °C with a distal aortic cannula and a femoral vein cannula. Only one cannula was needed to perfuse the brain, and blood passed in a retrograde fashion down the other carotid, protecting the brain from emboli. 

The innominate artery was clamped proximally before the arch was clamped. The aorta was then opened in this eighty-one-year-old patient and resected to just above the aortic valve. Fourteen to fifteen 2-0 Dacron sutures were placed in a horizontal mattress fashion to the proximal aorta in a similar technique to the way sutures are placed for proximal anastomosis of the aortic valve. 

When the head was cooled to 20 °C, the aortic clamp was removed, the aortic cannula was removed, and the aorta was inspected from inside. A Carrel patch was then made for the head and neck vessels. 

Next, 2-0 Ethibond sutures were placed into the distal aorta with horizontal mattress sutures in exactly the same way as the sutures were placed to the proximal aorta. Of note, no dissection was performed outside of the aorta, which the author believes is safer and quicker. In addition, this technique is better than a running 3-0 suture technique, in the opinion of the author, as it can get tangled and is more difficult to perform perfectly. 

The frozen elephant trunk graft was then sutured into place with interrupted sutures. The aortic graft was clamped and the body was perfused again for 10 minutes. The perfusion was then stopped again and the patch was sutured, along with the head and neck vessels, back onto the graft. The double-bite technique was used, with Dacron sutures to invert the graft, which the author feels is more hemostatic. The aortic clamp was then applied, the body was perfused again, and proximal anastomosis was completed using the double-bite technique. After this, the clamp was removed and the heart was restarted. Finally, the clamp and the cannula were removed from the innominate artery.

The author feels that this technique reduces the time of the operation by around an hour, as the body does not need to be rewarmed at the end of the case. 


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