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Modified Frozen Elephant Trunk technique
and reduced distal circulatory arrest time give better results in Type A acute aortic dissection.

Giampiero Esposito, Samuele Bichi, Antonio Massimo Cricco, Claudio Roscitano, Matteo Parrinello, Giovanni Albano.
Humanitas Gavazzeni, Bergamo, Italy.

OBJECTIVE: Nowadays Frozen Elephant Trunk (FET) technique represents a frequently used system for treatment of Type A acute dissection (TAAAD) as well as extensive aortic pathology. Nevertheless the FET approach require prolonged extracorporeal circulation (ECC) and distal circulatory arrest (DCA) with inherent risk of multiorgan complication. We report our short-term results with FET approach using a custom made short-cuff FET prosthesis associated with significant reduction of DCA and ECC due to rapid delivery of the stent-graft and subsequent quick perfusion of the distal downstream aorta through a high-flow balloon catheter inserted into the endoprosthesis.
METHODS: Between October 2012 and October 2014 21 patients (mean age 65,6±8,9 years) with TAAAD underwent emergency FET procedure. In all patients the usual antegrade cerebral perfusion was associated to selective left subclavian artery perfusion to ensure an adequate spinal chord protection. After the proximal aortic-root procedure a short-cuff FET prosthesis (stent-graft length 130mm and integrated vascular graft of 20mm) was rapidly implanted and fixed in Criado’s aortic zone 2. Than a balloon catheter, connected with a low-flow perfusion line, was inserted in the stent-graft portion to obtain a distal perfusion pressure of 30-40 mmHg in the femoral artery. The operation was sequentially completed with distal aortic anastomosis and rerouting of epiaortic vessels using a Dacron multibranched graft prosthesis.
RESULTS: Overall in-hospital mortality was 1/21 (4,76%). ECC time was 167,4±57,6 min, cross-clamp time was 101,5±40,1. Selective cerebral perfusion time (51±15 min) and visceral ischaemic time (15,8±3,3 min) were obtained thanks to the easy and rapid delivery of stent graft together the distal aortic perfusion. Analyzing the post-operative data we observed an ICU-length of stay of 4,07±2.3 days, AKI 1/2/3 respectively of 30,7/7,7/0%, no paraplegia and neurological damage, no bowel and liver dysfunction. No patients was re-explorated for bleeding. The short-term follow-up demonstrate a 100% survival with complete false-lumen thrombosis in 16/20 patients (80%). Endovascular adjunctive repair was necessary in 4 patients (20%).
CONCLUSIONS: FET procedure in TAAAD, performed with use of a custom made short-cuff FET prosthesis, was associated with significantly shortened ischaemic time producing excellent results in terms of mortality and post-operative complications.

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