Discussion
The frozen elephant trunk (FET) technique has rapidly gained acceptance and—despite its complexity—represents the treatment of choice for chronic aortic disease in many centers,2,3 but its use in acute dissection is still debated.4–6 Since 2018, Thoraflex Hybrid is our FET device of choice because of the advantages of the branched plexus configuration but LSA anastomosis remains its Achilles heel.7 To address this, we debranch and selectively cannulate the LSA and LCA with interposition of 10/8 mm Dacron prosthesis avoiding direct cannulation and optimizing bilateral cerebral perfusion (always trivascular). However, it can be difficult to trim the graft length and position it in the chest often resulting in redundant or kinked branch vessels, particularly in small chests, and difficulty in closing the sternum.
In this case, the second surgical graft was free to move and we made a direct end-to-end anastomosis while perfusing the vessels via the side branch. Cerebral perfusion is complete and continuous in our standard practice; HCA and operation times are shortened and probably contribute to a low incidence of major stroke, even in acute dissections (2.3% [1/42]; 1.3%, [1/74] all implants, data pending publication) compared to the literature (5—14%).7,8 With this device modification, the vessel lengths are more appropriate and the position of the neo-vessels in the chest avoids malpositioning and/or kinking, and facilitates sternum closure.