The Frozen Elephant Trunk Technique: European Association for Cardio-Thoracic Surgery Position and Bologna Experience

Abstract

Complex lesions of the thoracic aorta are traditionally treated in 2 surgical steps with the elephant trunk technique. A relatively new approach is the frozen elephant trunk (FET) technique, which potentially allows combined lesions of the thoracic aorta to be treated in a 1-stage procedure combining endovascular treatment with conventional surgery using a hybrid prosthesis. These are very complex and time-consuming operations, and good results can be obtained only if appropriate strategies for myocardial, cerebral, and visceral protection are adopted. However, the FET technique is associated with a non-negligible incidence of spinal cord injury, due to the extensive coverage of the descending aorta with the excessive sacrifice of intercostal arteries. The indications for the FET technique include chronic thoracic aortic dissection, acute or chronic type B dissection when endovascular treatment is contraindicated, chronic aneurysm of the thoracic aorta, and chronic aneurysm of the distal arch. The FET technique is also indicated in acute type A aortic dissection, especially when the tear is localized in the aortic arch; in cases of distal malperfusion; and in young patients. In light of the great interest in the FET technique, the Vascular Domain of the European Association for cardio-thoracic Surgery published a position paper reporting the current knowledge and the state of the art of the FET technique. Herein, we describe the surgical techniques involved in the FET technique and we report our experience with the FET technique for the treatment of complex aortic disease of the thoracic aorta.

Long-term Follow up of Patients with Acute Aortic Syndromes: Relevance of both Aortic and Non-aortic Events

“…In the current practice, if the aortic arch must be replaced end to end anastomosis is performed between the prosthetic graft and the aorta beyond the left subclavian artery, usually with the "frozen elephant trunk" approach, in order to stabilise the proximal portion of the descending aorta. 11,12 However, despite the "elephant trunk" technique being used increasingly to treat complex pathologies of the aortic arch and/or of the descending aorta, including AAS, the costs in terms of increased acute phase morbidity (bleeding, stroke, spinal cord injury, acute kidney injury) and mortality, and the effective number of patients needing a second intervention during follow up are still debated. 13 Five of 24 patients treated with this strategy also needed an endovascular re-intervention for dilation of the thoracoabdominal aorta during follow up.…”

Total aortic arch replacement using elephant trunk or frozen elephant trunk technique: a case-control matching study

“…The FET technique offers the option of definitive treatment of combined and extensive lesions in a single-stage procedure (3). The FET technique indications include several conditions such as Type A and B, acute and chronic aortic dissections as well as atherosclerotic aneurysms involving the aortic arch and the descending thoracic aorta (1,10). Due to the encouraging short-and mid-term results of the FET, this technique has become increasingly common (11)(12)(13).…”

“…Various prostheses have been developed in Europa for FET technique. The E-Vita Open Plus (Jotec GmbH, Hechingen, Germany) was the first commercially available hybrid prosthesis (1). The most widely used Thoraflex hybrid device (Vasutek Terumo, Inchinnan, Scotland, UK) was introduced in 2012 (1).…”

“…Our surgical approaches have been previously described in detail (1,6,8). All patients were operated on through median sternotomy.…”

Frozen elephant trunk technique: Ready to get back to the future?

“…Gore & Associates, Newark, Del), which allows us to perform a sutureless endoluminal anastomosis. 4 Others have proposed a fenestrated FET, in which a hole is manually created in the stent portion of the graft and a covered stent is then released inside the LSA to seal the artery at the time of surgery. 5 In this issue of the Journal, Okamura and colleagues 6 have proposed a modification to further simplify the FET technique further in cases of acute type A aortic dissection.…”