Early results of a novel single-stage hybrid aortic arch replacement technique to reduce bypass and circulatory arrest duration

Objective: Hybrid repair procedures of the aortic arch have been used to reduce surgical risks and have been applied to patients who would not traditionally be candidates for open surgical repair. We present a variation on the frozen elephant trunk technique to further reduce cardiopulmonary bypass and circulatory arrest duration. Methods: After initiation of cardiopulmonary bypass and during systemic cooling, a wire is advanced from the femoral artery into the aortic arch. In the case of aortic dissection, intravascular ultrasound is used to confirm true lumen placement. Under circulatory arrest, the proximal aortic arch is resected, and the wire is externalized. Antegrade deployment of a stent graft is performed into the aortic arch and proximal descending aorta. The ascending aortic graft is sewn to the cut end of the aorta, incorporating the stent graft. The graft is cannulated, and cardiopulmonary bypass is reinitiated. The remainder of the arch replacement is performed during rewarming. Compared with the frozen elephant trunk procedure, in which a Dacron graft is inserted into the descending aorta and later fixed with an endograft, this technique allows for immediate distal fixation. In the case of aortic dissection, there is immediate expansion of the true lumen with distal seal, potentially obviating the need for additional procedures. Results: Twenty-two patients underwent this novel hybrid arch replacement procedure for aortic pseudoaneurysm, aortic dissection, or aneurysm. Mean duration of follow-up was 12 months (range 1-14). The mean duration of cardiopulmonary bypass was 109.32 ± 3.14 minutes, and mean duration of circulatory arrest was 18.00 ± 1.33 minutes at a mean temperature of 23.64°C ± 0.58°C. There were no mortalities, permanent disabling strokes, or cases of renal failure requiring dialysis. Conclusions: This novel hybrid technique for aortic arch replacement is safe, significantly reduces cardiopulmonary bypass and circulatory arrest times, and is performed readily without need for fluoroscopy. In patients with thoracoabdominal aneurysms, the stent graft can be used as an elephant trunk for further thoracoabdominal aneurysm repair or branched thoracic endovascular aortic repair procedures.