Hybrid Arch Frozen Elephant Trunk Repair With a Multibranched Hybrid Graft

The hybrid arch frozen elephant trunk (FET) technique has been developed to enable the single-stage treatment of patients with complex aortic dissection or extensive aortic aneurysm disease.^{1 –4} We demonstrate this technique (Supplemental Video) in a patient with aneurysm disease using the multibranched, Thoraflex™ Hybrid prosthesis (Terumo Aortic, Inchinnan, UK). The technique relies on a surgically sewn proximal arch anastomosis, commonly performed between zone 0 and 2, with a distal endograft landing into the descending thoracic aorta. The FET is ideally deployed over a guidewire to ensure straight and targeted deployment into the intended 2 to 3 cm landing zone with approximate 10% to 15% oversizing in aneurysms and nominal sizing to the true lumen diameter in aortic dissection. In this case, the FET aims to seal the aorta at the landing zone, excluding the arch aneurysm and creating an optimal foundation to extend further distally with future endografts or surgical reintervention, if required. The epiaortic arch branches are reconstructed either with a separate head vessel graft or using multibranched graft designs, which enable anatomic head vessel reconstruction. We demonstrate a zone 2 anastomosis, our most commonly used approach, which facilitates a more proximal anastomosis to ease sewing and to minimize the risk to the recurrent laryngeal nerve. The head vessel branches are then constructed in reverse order from subclavian to carotid to innominate artery with this arch-first technique during rewarming. Conversely, a head vessel-first technique can be used with a separate head vessel graft during cooling and a straight, anteflow Thoraflex hybrid graft. The operations are performed with standard cannulation and antegrade cerebral perfusion strategies for brain protection, commonly using moderate hypothermic circulatory arrest.

The hybrid arch FET operation has a learning curve ⁵ but has been associated with good early and midterm outcomes.^{1 –4} Branch vessel patency rates remain extremely high, and the FET is extremely durable with low rates of unintended endoleaks. In cases where the FET hangs free within an aneurysmal descending thoracic aorta, efforts should be made for early endovascular extension to stabilize the distal aorta. FET complications are uncommon but can include stroke, spinal cord injury (SCI), and FET thrombus. Using shorter FET lengths and avoiding deep implantation beyond T7 to T8 can minimize SCI risk. FET thrombus remains poorly understood, can occur in all FET grafts, and can be treated with anticoagulation.

The hybrid arch FET operation has revolutionized care for patients with complex aortic arch and proximal descending aortic disease. Continued vigilance and comprehensive follow-up are key to ongoing quality improvements in care. Rigorous research and design innovations will be important to refine, enhance, and advance this novel surgical technique.