Re-do Total Aortic Arch Replacements with Elephant Trunk (Classical & Frozen): A Technical Challenge?

Objectives: Re-do total aortic arch replacements with elephant trunk ((classical (ET) & frozen (FET)) remain a formidable technical challenge. We present our single center experience in this high risk cohort.

Methods: Between 8/2001 and 3/2014, a total of 277 total aortic arch replacements with classical (n = 97) and frozen Elephant trunks (n = 180) were performed in our center. Out of these, 68 (ET=19; FET=49) patients were Re-do cases (mean age 55.4 years, male n = 49).

Previous operations were: 20 aortic valve (AVR) + aortic replacements, 13 aortic valve repairs, 13 ascending aortic replacements and 30 others.

Indications included aortic aneurysms (n = 23) and aortic dissections (Type A and B, n = 45).

Concomitant procedures included: Bentall, n = 21, David n = 2, AVR n = 16, Mitral Valve Replacement n = 2.

Results: Cardiopulmonary bypass, X-clamp and hypothermic arrest times were 255.3 ± 77.3, 135.3 ± 55.8, and 64.1 ± 34.1 minutes, respectively.

Incidence of re-thoracotomy for bleeding, stroke, prolonged ventilatory support (> 96 hours) and acute temporary renal failure requiring dialysis were 26.5%, 11.8%, 25% and 17.7%, respectively. In-hospital mortality was 14.7%.

Mean follow-up was 59.6 ± 48.9 months. During follow-up, 11 Patients underwent an open thoraco-abdominal aortic replacement and 6 patients, a TEVAR procedure and 3 abdominal aortic repairs.

Conclusions: With modern techniques, re-do total aortic arch replacements can be performed with acceptable short & long-term results. In view of these results, the argument toward TEVAR in all re-do aortic arch surgery should be discussed. Noven techniques such as 'Beating heart' aortic arch replacement to reduce myocardial ischaemia time may further reduce peri-operative mortality. However, it is advisable that such surgery be performed in carefully selected patients.