The Thoraflex™ Hybrid Prosthesis is commonly used on the proximal aorta in patients with aortic aneurysm and aortic dissection (Stanford Type A). Of the two patients treated with this procedure, the first patient underwent a supracoronary aortic replacement with the Frozen Elephant Trunk procedure and needed treatment of the thoraco-abdominal aorta due to progressive true lumen collapse as a result of continued perfusion of the false lumen and symptoms related to reduced perfusion of the abdominal organs. The 3-D reconstruction of the CT-angiography of this patient before and after replacement of the thoracoabdominal aorta is included in the figure above. The second patient, who had Loeys-Dietz syndrome, first underwent a Bentall procedure with a mechanical aortic valve, then the Frozen Elephant Trunk procedure to replace the aortic arch and proximal descending aorta. Due to the underlying disease and progression of the aneurysm with continued perfusion of the false lumen, the distal descending aorta (thoracoabdominal aorta) needed treatment. In both cases, continued false lumen perfusion, risk of rupture due to rapid progression of the aortic aneurysm, difficult anatomy for reconstruction using endovascular techniques were the reasons for selection of this procedure.
Though TEVAR was considered in both patients, it was not feasible due to difficulty in establishing reliable vascular access, as well as a narrow landing zone in the progressive aneurysm of the descending aorta. A TEVAR extension alone would not have sufficiently excluded the proximal descending aorta from retrograde perfusion.
During the procedure, the stent portion of the prosthesis is inserted manually under direct vision of the landing zone. This prevents the occurrence of distal stent graft–induced new entry. As both cases presented with chronic dissection, where the occurrence of iatrogenic re-entry has been shown to occur more frequently 3, a surgical approach may provide a significant advantage over endovascular approach in this area. Furthermore, this technique is faster and technically easier than using a tube graft to reconstruct the descending aorta up to/ just beyond the diaphragm.
There were no neurological complications in both cases, although this technique should not inherently affect the occurrence of such complications, as compared to other procedures on the thoracoabdominal aorta and may require further evaluation.
Another disadvantage could be that of leaving a potentially perfused false lumen at the level of the second hybrid prosthesis stent graft. However, if a re-entry at the expected level can be ruled out pre-operatively, as was the case with the patients treated, the chances of this are minimal.
Though not performed in the cases presented, this procedure has the potential of being combined with reconstructions of the abdominal aorta when required.
This procedure shows that the descending aorta including the transition to the abdominal part of the aorta can be treated using the Thoraflex™ Hybrid Ante-Flo™ prosthesis. The inflow of the left-left bypass can easily be achieved by using the perfusion arm of the prosthesis without the need for additional vascular access. Using this technique, operative time is reduced with accurate reconstructions of the anatomy.