Discussion
The frozen elephant trunk (FET) technique has rapidly gained acceptance
and—despite its complexity—represents the treatment of choice for
chronic aortic disease in many centers,2,3 but its use
in acute dissection is still debated.4–6 Since 2018,
Thoraflex Hybrid is our FET device of choice because of the advantages
of the branched plexus configuration but LSA anastomosis remains its
Achilles heel.7 To address this, we debranch and
selectively cannulate the LSA and LCA with interposition of 10/8 mm
Dacron prosthesis avoiding direct cannulation and optimizing bilateral
cerebral perfusion (always trivascular). However, it can be difficult to
trim the graft length and position it in the chest often resulting in
redundant or kinked branch vessels, particularly in small chests, and
difficulty in closing the sternum.
In this case, the second surgical graft was free to move and we made a
direct end-to-end anastomosis while perfusing the vessels via the side
branch. Cerebral perfusion is complete and continuous in our standard
practice; HCA and operation times are shortened and probably contribute
to a low incidence of major stroke, even in acute dissections (2.3%
[1/42]; 1.3%, [1/74] all implants, data pending publication)
compared to the literature (5—14%).7,8 With this
device modification, the vessel lengths are more appropriate and the
position of the neo-vessels in the chest avoids malpositioning and/or
kinking, and facilitates sternum closure.