Roberto Di Bartolomeo

Perspectives from Bologna on the future directions of aortic surgery Mohamad Bashir, Davide Pacini, Roberto di Bartolomeo

The frozen elephant trunk might be considered one of the most appreciated innovations during the last decades to treat complex thoracic aortic lesions. Many useful tips have been progressively introduced to standardize the procedures and, nowadays, the improved post-operative outcomes contributed to spread the procedure. The following article will provide a comprehensive review analysis of the Frozen Elephant Trunk (FET) technique, throughout the current available devices, possible surgical indications and primary post-operative complications.

Special Edition on The Ninth Postgraduate Course on “Surgery of The Thoracic Aorta” in Bologna

Total aortic arch replacement with frozen elephant trunk (Thoraflex)

The elephant trunks, either conventional or frozen represent the major technical improvements in the treatment of complex thoracic aortic disease. In the last decades, these useful techniques progressively evolved along with the introduction of new devices to facilitate the procedure and ameliorate post-operative results. The latest multi-branched hybrid FET prostheses give us the opportunity to greatly facilitate graft implantation and reduce operative times. The following review will provide an overview of the FET technique throughout the current available devices, possible surgical indications and principal surgical steps.

Acute type A aortic dissection (AAAD) remains one of the most challenging diseases in cardiothoracic surgery and despite numerous innovations in medical and surgical management, early mortality remains high. The standard treatment of AAAD requires emergency surgery of the proximal aorta, preventing rupture and consequent cardiac tamponade. Resection of the primary intimal tear and repair of the aortic root and aortic valve are well-established surgical principles. However, the dissection in the aortic arch and descending untreated aorta remains. This injury is associated with the risk of subsequent false lumen dilatation potentially progressing to rupture, true lumen compression and distal malperfusion. Additionally, the dilatation of the aortic arch, the presence of a tear and retrograde dissection can all be considered indication for a total arch replacement in AAAD. In such cases a more aggressive strategy may be used, from the classic aortic arch operation to a single stage frozen elephant trunk (FET) technique or a two-stage approach such as the classical elephant trunk (ET) or the recent Lupiae technique. Although these are all feasible solutions, they are also complex and time demanding techniques requiring experience and expertise, with an in the length of cardiopulmonary bypass and both myocardial and visceral ischemia. Effective methods of cerebral, myocardial as well visceral protection are necessary to obtain acceptable results in terms of hospital mortality and morbidity. Moreover, a correct assessment of the anatomy of the dissection, through the preoperative angio CT scan, in addition to the clinical condition of the patients, remain the decision points for the best arch repair strategy to use in AAAD.