Hybrid aortic arch and frozen elephant trunk reconstruction: bridging the gap between conventional and total endovascular arch repair

Abstract

Novel endovascular techniques hope to offer patients aortic arch repair with reduced morbidity compared to conventional arch surgery; however, current endovascular strategies remain challenged by the proximal seal zone, higher stroke rates, long-term durability and select anatomy. Hybrid arch repair offers patients a less invasive alternative that can treat more distal aorta than conventional arch repair yet still be performed via standard sternotomy. Areas covered: This review will discuss the current evidence and future development of hybrid aortic arch and frozen elephant trunk reconstruction. Several approaches to hybrid arch repair are summarized, including the off-label use of thoracic endovascular stent-grafts and commercially manufactured hybrid grafts. Technical considerations and clinical outcomes with each approach will be addressed along with advantages and disadvantages. Expert commentary: Hybrid arch repair will undergo continued refinement as our ability to provide a less-invasive alternative to conventional open arch repair grows. Evolution to allow for improved head vessel branch sizing, improved frozen elephant trunk deployment accuracy, monitoring to prevent paraplegia and utilization of intraoperative image guidance in hybrid operating rooms is necessary. The potential exists for hybrid approaches to arch pathology to completely supplant conventional surgery, while avoiding the potential deleterious complications of total endovascular repair.

Dissected Aorta Repair Through Stent Implantation trial: Canadian results

“…Although this technique is a sensible approach to elective complex arch aneurysms, when applied to treatment of acute dissections it will extend an already challenging operation in gravely ill patients, increase the time on cardiopulmonary bypass, circulatory arrest, and selective cerebral perfusion. 15 The FET also exposes the patient to additional risks of stroke, bleeding, and paralysis due to the extended operation requiring the resection and replacement of the aortic arch and the supra-aortic branches and the obstruction of the blood supply to the spinal cord if the FET coverage is more than 10 cm. 16 To date no prospective controlled trial has assessed the efficacy of using a short FET in the descending aorta and most publications have been on the basis of the experiences of individual institutions with a great interest in the FET technique.…”

Early Clinical Outcomes of Hybrid Arch Frozen Elephant Trunk Repair With the Thoraflex Hybrid Graft

“…Classic 2-staged sternotomy and thoracotomy approaches or the single-staged clamshell approach remain the gold standard treatment of extensive aortic arch disease but are associated with significant morbidity and prolonged recovery [1][2][3][4][5]. Alternatively, total endovascular arch repair offers a much less invasive approach but require significant intravascular manipulation and have been associated with significant risk of stroke, endoleak, and unknown late durability [6]. The frozen elephant trunk (FET) technique provides an attractive Accepted for publication July 30, 2018. option to treat more extensive multisegment aortic disease, and in some cases allows for a single-stage reconstruction by combining both open and endovascular techniques [6][7][8][9].…”

“…Alternatively, total endovascular arch repair offers a much less invasive approach but require significant intravascular manipulation and have been associated with significant risk of stroke, endoleak, and unknown late durability [6]. The frozen elephant trunk (FET) technique provides an attractive Accepted for publication July 30, 2018. option to treat more extensive multisegment aortic disease, and in some cases allows for a single-stage reconstruction by combining both open and endovascular techniques [6][7][8][9]. The FET reduces the need for a second operation and the potential interstage mortality associated with delayed distal aortic repair [9,10].…”

“…Most of the FET experience in North America has relied on "off-label" use of thoracic endografts with hybrid debranching operations that have been associated with higher risks of stroke and endoleak [11]. There have been a number of commercially available hybrid arch FET grafts in Europe being used with growing success [6,[12][13][14][15][16]. The Thoraflex Hybrid graft (Vascutek, Glasgow, Scotland) is a novel single piece 4-branch arch graft with a distal nitinol-ringed Dacron stent graft that enables repair of extensive arch and descending aortic disease.…”

Hybrid arch frozen elephant trunk repair: evidence from the Canadian Thoracic Aortic Collaborative

“…The frozen elephant trunk (FET) technique for reconstruction of the aortic arch has become an established strategy to address extensive thoracic aneurysms or dissections through a median sternotomy (1)(2)(3)(4). Compared to a conventional elephant trunk, the FET has several potential benefits: (I) it permits single stage repair for extensive aneurysmal disease limited to the thoracic aorta; (II) delays or avoids a second stage repair in patients with chronic dissections; (III) reduces the likelihood of kinking, obstruction, or accordioning compared to a soft conventional elephant trunk and facilitates distal endovascular repair; (IV) in the setting of acute DeBakey I aortic dissection, a FET may be particularly advantageous in improving distal malperfusion and promoting favorable early and late distal aortic remodeling.…”