A team of cardiac and vascular surgeons successfully performed a modified version of the frozen elephant trunk (FET) technique to treat a middle-aged patient with heart disease.
The procedure – a complex, one-stage hybrid surgery for diseases of the aortic arch and descending aorta – combines open surgery with endovascular stenting.
It replaces the aortic arch with a graft, deploys a stent-graft in the descending aorta to stabilise it, expands the true lumen and collapses the false lumen, thereby improving long-term outcomes and preventing a second operation.
However, this is believed to be the first time surgeons have ever employed this particular approach.
First author Enrico Rinaldi, a researcher with the vascular surgery unit at the San Raffaele Scientific Institute in Italy, and colleagues, said: ‘Combining open surgery with endovascular repair, the FET technique facilitates complete arch replacement and has become a widely accepted strategy for treating complex aortic arch diseases.
‘Encouraging results with this method have led to the development of several FET devices for commercial use, available in both off-the-shelf and custom-made configurations. Despite advancements in device technology, commercially manufactured FET systems are not universally accessible and may be unavailable for urgent or emergency use in specific centres. To address these challenges, alternative techniques inspired by the same principles have been described, showing encouraging outcomes but also presenting some drawbacks.’
Rinaldi et al. detailed their experience treating a 57-year-old patient who first presented at their outpatient clinic. He had previously undergone a type A aortic dissection in 2018, managed with a Bentall procedure, aortic valve replacement and a hemiarch replacement. However, he did not attend follow-up appointments as recommended.
He then underwent a thoracic CT angiogram after a car accident. The imaging results revealed a 5.9cm aortic arch aneurysm associated with residual dissection, and elective aortic arch replacement using the FET technique was identified as the preferred treatment option.
The patient first underwent a left carotid-to–subclavian artery bypass, and that procedure was seen as a success. The patient was discharged four days following the operation, and the aortic arch repair was planned for 15 days later. During the time between planned procedures, however, the patient presented to the emergency room with ‘acute thoracic pain’.
New imaging results confirmed he had an ‘impending aortic rupture’ and an emergency FET procedure was required.
The standard device used for the FET technique was unavailable, and, given the urgency of the patient’s condition, the surgical team determined that they could not wait for the part to be ordered; they had to act immediately.
They chose to recreate the FET technique by combining a standard thoracic stent graft with a surgical graft. The modification process took 65 minutes.
The new approach, ‘C-tag Endograft SanRaffaele Arrangement to Re-create a frozen Elephant trunk (CESARE)’, had the desired result.
The patient was discharged one week after treatment. Follow-up imaging three months later confirmed that the procedure was successful.
Click here to read the full study.
