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Management of left subclavian artery in total arch replacement and frozen elephant trunk procedure

From the Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China; Vascular & Endovascular Surgery, Royal Blackburn Teaching Hospital, Blackburn, United Kingdom; and Department of Thoracic and Cardiovascular Surgery, West German Heart Center Essen, University Hospital Essen, Essen, Germany. Informed consents for publications have been obtained from patients involved. Disclosures: Drs Bashir and Jakob are consultants to CryoLife. Dr Bashir received an educational grant from CryoLife for the preparation of this manuscript. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Received for publication March 21, 2021; accepted for publication March 22, 2021; available ahead of print March 21, 2021. Address for reprints: Randolph H. L. Wong, MBChB, FRCS, Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China (E-mail: wonhl1@surgery.cuhk.edu.hk). JTCVS Techniques 2021;7:36-4

The advent of frozen elephant trunk (FET) revolutionized open surgical management of total aortic arch aneurysm disease. 1,2 However, one of the challenges is the left subclavian artery (LSA) anastomosis, which is often deep and difficult to visualize. The emerging use of E-vita OPEN NEO (JOTEC, Hechingen, Germany) is a promising approach to tackling this challenge. We report our early experience and describe the advantages of its design in facilitating anastomosis of the LSA. The new arch branched graft E-vita OPEN NEO was introduced to our center in October 2020. Between October and November 2020, 3 patients underwent total arch replacement using FET with the branched version of E-vita OPEN NEO. The operations were elective, the pathology was type III aortic dissection with arch aneurysm, and none had undergone previous aortic surgery. Perioperative data were collected retrospectively from institutional database with the patients' informed consent (Table 1). Mean operative time and circulatory arrest time were 315 AE 79 minutes and 47 AE 2 minutes, respectively. Selective antegrade cerebral perfusion (SACP) was delivered to all 3 supra-aortic branches during the procedure, and the mean SACP time was 138 AE 1 minutes. The mean hospital length of stay was 10 AE 1 days. No permanent spinal or neurologic complications or injury to the recurrent laryngeal nerve were observed. There was no in-hospital mortality.

OPERATIVE TECHNIQUE
We previously reported our approach to total arch replacement using FET. 3 Using the novel device, we adopted the distal-proximal-supra-aortic sequence of anastomosis, under diastolic cardiac arrest, moderate hypothermic circulatory arrest between 25 o C and 28 o C, and SACP to all 3 supra-aortic vessels. In all cases, the left subclavian artery was perfused with antegrade cerebral perfusion during circulatory arrest and before revascularization. It was the first revascularized supra-aortic branch after the proximal aortic anastomosis. Two patients had deployment of FET with a 0.035" guidewire passed

CENTRAL MESSAGE
The 20-mm cuff-to-last branch distance in E-vita OPEN NEO facilitates left subclavian artery anastomosis and the overall graft orientation in total arch replacement with frozen elephant trunk.  Figure 1, B-1 shows a more commonly presented orientation in which the LSA was found deeper into the mediastinum (Figure 1, B-2), with an extension of the LSA required for better exposure. The extension of the LSA was done with a segment of the 10mm branched graft from the E-vita OPEN NEO on circulatory arrest (Figure 2, B-1). After stent deployment into the descending aorta and distal anastomosis, the LSA anastomosis was completed with a graft-to-graft anastomosis (Figure 2, B-2).
On rarer occasions (as in Figure 1, C-1 and C-2), the LSA was not only deep, but also apically located, an extra-anatomic bypass of the left axillary artery and ligation of the LSA origin was required. The left axillary artery bypass was performed with a 6-mm graft under an infraclavicular incision. After stent deployment into the descending aorta and distal anastomosis, the vascular graft was tunneled through the first intercostal space and the left pleural cavity to reach the mediastinum for anastomosis

DISCUSSION
In total arch replacement with FET, zone 2 anastomosis has been associated with improved survival. [4][5][6][7] However, this approach is fraught with technical challenges, as the LSA can be deep and thus challenging, and various approaches and decision algorithms have been described. [6][7][8] The 3 approaches to LSA anastomosis described here allow better planning for full restoration of the supra-aortic branches, including the anticipated approach to achieve proximal control for anastomosis with good hemostasis in our experience. The 20-mm