Arch replacement with collared elephant trunks: The Siena approach

Abstract

Objective: To illustrate our experience and results in patients with diffuse aneurysmal disease treated with arch replacement using the Siena collared graft, a device designed in 2002 to improve the elephant trunk technique. Results of the first step surgical implant and the subsequent treatment strategies, with extensive use of endovascular techniques, are reported.Methods: All aortic arch-replacement procedures using the Siena graft between February 2002 and January 2020 were retrospectively analyzed for early and late clinical outcomes.Results: Of 146 patients (54 women, 36.9%) with a median age of 69.1 years (interquartile range 58.4-75.0 years), 55 (37.6%) had acute/chronic dissection with false lumen aneurysmal dilatation, 91 (62.3%) had degenerative aneurysms, 45 (30.8%) were redo operations, and 14 (9.5%) had connective tissue disease. First-stage outcomes: 10.9% 30-day mortality (n ¼ 16); 5.4% stroke (n ¼ 8, 6 disabling, 2 nondisabling; 3 fatal); and 0.6% paraplegia. Outcomes for 113 second-stage procedures (77.3%, n ¼ 97 endovascular [66.4%], n ¼ 16 surgical [10.9%]) were 5.3% and 8.8% 30-day and 180-day mortality; no stroke; 10.6% paraplegia. Median followup was 5.7 years (range: 0-18.02 years) median survival was 16.65 years (95% lower confidence limit, 10.06 years) with no significant difference between aneurysm and dissection patients. Freedom from further treatment was 87.0% (95% confidence interval, 79.9%-94.7%) at 5 years and 71.4% (95% confidence interval, 71.4%-84.7%) at 10 years; median time to reintervention was 2.59 years (interquartile range, 0.52-5.20 years) with no difference (P ¼ .22) between dissection and aneurysm groups.Conclusions: Siena collared graft represents a reliable platform for the treatment of diffuse aneurysmal disease. This device offers the flexibility required in the treatment of extended aortic lesions and guarantees the choice of the most appropriate approach for treatment completion. In this context, the availability of hybrid grafts has not modified the role of this device in arch surgery. (JTCVS Techniques 2021;6:13-27) Three steps of a "delayed frozen" elephant trunk approach.

Extra-anatomical left common carotid and subclavian artery bypass followed by aortic arch replacement with frozen elephant trunk

“…3 ). Our multiple stages of open aortic surgery with endovascular intervention may be effective in achieving the goal of improving the outcome in high-risk patients, which is consistent with a previous study using a collared elephant trunk prosthesis for TAR and subsequent TEVARs for diffuse thoracic aneurysm [ 25 ]. TEVAR had been intentionally delayed after TAR, which was followed by additional TEVAR to cover the residual lesion in the aorta (so-called three steps of delayed frozen elephant trunk approach).…”

Transapical total aortic arch replacement with three-branched endograft for penetrating aortic ulcer

“…For the present patient, we chose TAA to achieve a smooth passage of the main body of the graft despite the significant angulation of the arch. 5 Moreover, the use of a transapical TT wire allows for the passage of the main body at the center of the aorta, reducing the possibilities of scraping off arch plaque and the risk of embolization.…”

Surgical Approaches to Single-Stage Extended Aortic Repair from the Ascending to the Distal Descending Aorta

“…2 ) or by using a collared graft. 27) Unlike the FET operation, single-stage hybrid operations are not associated with high incidence of spinal cord ischemia. 26) Such operations seem useful for patients with poor pulmonary function but is associated with the problem of sac growth in the long term.…”