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Management oftheAortic Arch inAcute Aortic Dissection Type A
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anastomosed to the arch using a 4-0 polypropylene suture. In the past years we have
explored the use of the intussusception technique (Fig.7) as alternative to adhesive
and found it similarly effective. This type of arch repair can usually be accomplished within a cerebral ischemic time of less than 15min, and we therefore do not
employ antegrade cerebral perfusion.
If the entry is located in the convexity of the arch or in the proximal descending
aorta, a decision for total arch replacement is made. Our preferred approach to total
arch replacement is the modication proposed by the Griepp group [25, 34, 68],
since we feel it gives us best control of the operation and exposure of the distal
anastomosis while minimizing operative complexity (Fig.4).
As a rst step most of the aortic tissue is resected around the orices of the supraaortic branches. A 14 or 16mm Dacron graft is anastomosed to the island of the
origins of the head and neck vessels. Since the duration of hypothermic circulatory
arrest is less predictable under these circumstances, we then clamp the graft and
resume antegrade perfusion with a blood temperature of 15°C and a ow rate of
500ml/min. Alternatively (if the right axillary artery had not been used for arterial
cannulation) we place the aortic cannula into this arch graft and snug it with a tourniquet or clamp for antegrade perfusion.
A second graft is then chosen for the aortic arch. If the descending aorta is of
normal caliber, end-to-end anastomosis is created. In order to secure hemostasis,
either application of adhesive (Bioglue, CryoLife, Kennesaw, GA, USA) or the
intussusception technique are employed. We rarely employ Teon felt to buttress
the suture line; for the suture to the descending aorta, however, we always use it. If
the diameter of the descending aorta is larger than 3cm, either a short elephant
trunk extension or a frozen trunk are added. This seems particularly helpful if true
lumen compression was present on the preoperative CT.
After the distal suture is complete an opening is created on the cephalad circumference of the aortic graft. The smaller graft connected to the head and neck vessels
is shortened and implanted into the aortic prosthesis. Full aortic perfusion is
restarted, and hemostasis can be checked on the two anastomoses.
If a complex entry is present between the origins of the supraaortic orices we
choose total arch replacement using a branched aortic graft. The distal aortic arch is
transected at just distal to the left subclavian artery take-off, taking care not to injure
the left recurrent nerve. The false lumen is obliterated by surgical glue, expanding
the true lumen with a Foley catheter.
A short tube graft with the same diameter of the distal aorta is inserted into the
true lumen as an elephant trunk (Fig.8). This will not only facilitate distal hemostasis but also improve reverse remodeling of the downstream aorta. The distal end of
the prefabricated arch graft with four branches is cut short and anastomosed to the
distal aorta using a 4-0 polypropylene suture with the graft inside and felt reinforcement outside. Subsequently the separate arch grafts are connected to the respective
arch vessels using 5-0 polypropylene running suture and perfusion is resumed
sequentially followed by gradual rewarming. After termination of selective cerebral
perfusion, full systemic rewarming becomes feasible. One of the advantages of
316
Mini elephant
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Fig. 8 Creation of the distal anastomosis in total arch replacement for AADA. A short graft
(5–8cm long) is introduced into the true lumen of the descending aorta and a Teon strip is placed
outside the aorta. The aortic graft is connected to the distal aorta, “sandwiching” the aortic wall
between the trunk graft and the Teon strip
T. Kunihara and H.-J. Schäfers
Felt strip
False lumen
trunk
individual branch reconstruction is small anastomosis with low tension and good
hemostasis.
Antegrade selective cerebral perfusion is performed through an individual circuit
and pump other than systemic one. Three balloon catheters (15Fr for the brachiocephalic artery, 12Fr for the left common carotid artery and the left subclavian
artery) are inserted into the true lumen of the three arch vessels. Total perfusion ow
is initially set at 12ml/kg and adjusted according to the bilateral radial artery pressures and regional cerebral oxygen saturation. When cannulation to the left subclavian artery is complicated, it can be clamped and perfusion ow is reduced. In case
of right axillary artery cannulation, all three arch vessels can simply be clamped at
their origin and cerebral perfusion can simply be performed through the right axillar
artery alone.
In patients with marked true lumen collapse preoperatively, the use of a frozen
elephant trunk can be considered aiming at early reverse remodeling of the downstream aorta. In this scenario, one or two arch vessels can be translocated, which
will also facilitate anastomosis and hemostasis. An advantage of this technique is
that injury of the left recurrent nerve or phrenic nerve can absolutely be avoided.
The aortic arch is transected just distal or proximal of the left common carotid artery
according to the location of primary intimal tear. The left subclavian artery with or
without the left common carotid artery are transected and their proximal ends are
closed. Each arch vessel is connected to the respective branch of the prefabricated
Management oftheAortic Arch inAcute Aortic Dissection Type A
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arch graft which originates from more proximal than natural anatomy (=translocation). A frozen elephant trunk is inserted into the true lumen of the distal aorta. Care
must be taken not to injure the intimal ap and not to extend it too far distally to
minimize the risk of spinal cord injury [29, 83]. The major drawback is kinking of
the branches of the prefabricated arch graft because of unfavorable angles.
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Dissection
EmidioGermano, KyleMiletic, andEricE.Roselli
The Problem
Interposition graft replacement of the ascending aorta only is the most commonly
performed operation for acute aortic dissection. However, arch and downstream
aortic dissection persist in the majority of patients following a limited conventional
repair and the patency of the downstream false lumen has been associated with
worse survival and risk for reoperation [1, 2]. Simultaneous replacement of the
ascending aorta and total arch during the primary procedure may improve outcomes
by providing better downstream perfusion and can potentially improve prognosis by
promoting earlier reverse remodeling of the aorta [3]. This approach has been criticized, however, for adding complexity to the initial emergency/high-risk procedure
[4]. Several modications to the conventional surgical approach to extend repair to
the arch have been described including the elephant trunk technique rst described
in the 1980s [5, 6]. Soon after the development of stentgrafts, stents were added to
surgical graft repairs to extend into the proximal descending aorta. This stent xation of the elephant trunk graft became the frozen elephant trunk [7–9].
Just as was seen with open arch repair, multiple variations of performing frozen
elephant trunk repair have been described. Most frozen elephant trunk operations
resemble the conventional operations in that a series of multiple anastomoses are
performed including the arch branch vessels. Ischemic times during these operations have been directly correlated with neurological risk and the risk of perioperative death [10–13]. The simple addition of a stented component has not necessarily
made the technological challenges of performing arch replacement readily accessible to most surgeons who may rarely perform thoracic aortic operations. There is an
unmet need in the treatment of aortic dissection involving the arch to provide a more
E. Germano · K. Miletic · E. E. Roselli (*)
Aorta Center, Department of Thoracic and Cardiovascular Surgery, Heart Vascular and
Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
e-mail: RosellE@ccf.org
J. S. Coselli et al. (eds.), Aortic Dissection and Acute Aortic Syndromes,
https://doi.org/10.1007/978-3-030-66668-2_23
323© Springer Nature Switzerland AG 2021
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extended repair without adding the increased neurologic and bleeding risk commonly associated with the conventional approaches to more extended repairs.
E. Germano et al.
Room forImprovement
With improvements in patient care such as improved imaging, more frequent use of
selective antegrade brain perfusion, and dedicated surgical teams performing cardioaortic operations, surgical outcomes for aortic dissection continue to improve [14].
It has been demonstrated that there is a volume to outcome relationship for treating
aortic dissection, and patients who present with end organ ischemia or malperfusion
still represent the greatest challenge in the acute phase [15]. During intermediate
follow-up, survival depends upon the patency of the downstream false lumen and
for a population of patients with an average age less than 60 years usually without
signicant coronary disease, the 5 year survival is rather poor [16]. An extended
operation at the time of acute dissection that optimizes true lumen ow distally
holds promise to improve distal malperfusion and promote the reverse remodeling
that may also improve later survival [17].
Novel Approaches
As thoracic endovascular devices have become more available, and cardio-aortic
surgeons have become more familiar with the characteristics and unique features
including advantages and limitations of these devices, they have been used more
commonly during open thoracic aortic operations as part of a hybrid reconstruction
strategy [18, 19]. Most commonly, TEVAR devices are used in combination with an
open repair to perform the so-called frozen elephant trunk repair for patients with
multi-segment disease. What is common to all of the frozen elephant trunks is: 1)
the use of a commercially available thoracic stentgraft device delivered in an antegrade fashion through the open aortic arch during a period of at least partial circulatory arrest (i.e. nearly always including selective antegrade brain perfusion); 2)
direct suturing of the stentgraft device to the patient’s native aorta.
These operations have become common at some larger centers of excellence
especially in Europe and Asia, but have not been widely adopted due to the complexity of these operations and the lack of dedicated devices (in the US). Furthermore,
there is not a standard for how these operations are performed.
The frozen elephant trunk operation can be performed on any patient with type 1
dissection. However, it is particularly helpful for patients with the retrograde aortic
dissection extending from a distal entry tear, those with the aneurysmal distal aorta,
distal malperfusion from a smaller true lumen, and those who are young or with
suspicion for a genetically triggered cause of aortic disease, placing them at higher
risk for later false lumen aneurysmal degeneration [20].
Frozen Elephant Trunk forAortic Dissection
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A Better Way
Our surgical technique of frozen elephant trunk repair in acute aortic dissection has
evolved over the last 10 years into what we refer to as the Branched Stented
Anastamosis Frozen Elephant trunk Repair [21, 22] (Fig.1). The latest iterations of
this procedure will be described later in this chapter.
The cornerstone to achieving successful outcomes for treating complex aortic
pathology is the creation of a multi-disciplinary Aortic Team that consists of emergency care transport, cardiology intensive care physicians (cardiology), cardiovascular imaging specialist (radiologists/cardiologists/radiology technicians),
cardiothoracic anesthesia, cardiovascular surgery, vascular surgery, hybrid trained
operating room nursing and perioperative nursing, and perfusion. The entire team is
alerted when a possible acute aortic dissection is en route with the goal to provide
comprehensive and expeditious care to patients with acute aortic syndromes using
standardized protocols with improved coordination and communication across the
various disciplines [23, 24] (Fig.2).
A careful analysis of contrast enhanced 3D computed tomography (CT) imaging
by the operating surgeon is essential to understand the individual patient’s anatomy,
the dissection morphology and to select the endograft devices used during the repair.
The stent graft sizing is done precisely based on the aortic measurements in cross
section to the centerline of ow, at the level of suturing in the arch (usually zone 1
or 2, adjacent to the left common carotid artery). Over sizing is avoided to minimize
abc
Fig. 1 Chronological evolution of the simplied frozen elephant trunk repair technique for acute
aortic dissection. (a) Left, 2009 version with a large scallop creation, (b) Middle, 2012 version
with on table fenestration, and (c) Right, latest version with direct bridging arch branch stent grafting—Branched Stented Anastomosis Frozen Elephant trunk Repair (B-SAFER). Image reprint
with permission [22]
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