Deceptive safety of unsupported fabric fenestrations in hybrid aortic arch replacement using the EB-SAFER technique.

The 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. The 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. With interest we read the article by Hashizume and colleagues,1Hashizume K. Matsuoka T. Mori M. Takaki H. Koizumi K. Kaneyama H. et al.Total arch replacement with extended branched stented anastomosis frozen elephant trunk repair for type A dissection improves operative outcome.JTCVS Techniques. 2023; 17: 1-9Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar reporting on 21 patients who underwent a modification of the B-SAFER technique (EB-SAFER) to simplify and speed up the anastomoses to the supra-aortic vessels in frozen elephant trunk treatment of acute aortic dissection. In their series, the circulatory arrest time significantly improved to 75 minutes and the short-term results were stable. In addition to previous criticisms and critical reports concerning the Cleveland technique of the B-SAFER anastomotic stenting by Guo and colleagues and Murana and colleagues,2Guo M. Naeem A. Yang B. The challenges of novel interventions in complex aortic disease.JTCVS Techniques. 2020; 4: 57-60Abstract Full Text Full Text PDF PubMed Google Scholar,3Murana G. Di Marco L. Pacini D. Commentary: novel interventions in complex aortic disease: a perfect storm to “B-SAFER”..JTCVS Techniques. 2020; 4: 61-62Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar it is necessary to point out that the concept, although intriguing, contradicts current developments and knowledge gained in complex endovascular aortic surgery. First, unsupported fabric fenestrations have significant risk of unpredictable long-term results. Endoleaks, occlusions, and migration have been repeatedly reported. Furthermore, although in situ fenestration in the aortic arch has demonstrated feasibility, great concerns exist regarding fabric tears, secondary target vessel instability, and possible material fatigue in the end.4Lin J. Rodriguez L.E. Nutley M. Jun L. Mao Y. Parikh N. et al.Optimal in situ fenestration technique with laser perforation and balloon dilation for aortic stent-grafts.J Endovasc Ther. 2021; 28: 300-308Crossref PubMed Scopus (7) Google Scholar Also, in addition to 3-dimensional movement of the arch with each cardiac cycle, recent reports show that the entire aorta may reposition and morphologically reconfigure itself within the thoracic cavity after endovascular repair.5Osswald A. Schucht R. Schlosser T. Jánosi R.A. Thielmann M. Weymann A. et al.Changes of stent-graft orientation after frozen elephant trunk treatment in aortic dissection.Eur J Cardiothorac Surg. 2021; 61: 142-149Crossref PubMed Scopus (8) Google Scholar This may be expected to cause considerable changes in force exerted on the anastomotic sites and further endanger the connections. In summary, branched endografts currently may be considered the far more favorable option in endovascular treatment of the aortic arch. They provide more stability, especially in a diseased arch where the main graft does not achieve perfect apposition to the aortic wall. Thus, the experience from thoracoabdominal endovascular surgery demonstrated higher rates of type III endoleaks in fenestrated repairs when the distance to the wall was more than 5 mm.6Chait J. Tenorio E.R. Mendes B.C. Lima G.B.B. Marcondes G.B. Wong J. et al.Impact of gap distance between fenestration and aortic wall on target artery instability following fenestrated-branched endovascular aortic repair.J Vasc Surg. 2022; 76: 79-87.e74Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Second, the use of self-expandable stents in fenestrations cannot be considered the standard of care any longer. Balloon-expandable stents are preferred, because flaring the part of the stent in the main graft increases stability and hemodynamics, and reduces the risk of dislocation.7Grima M.J. Wanhainen A. Lindstrom D. In situ laser fenestration technique: bench-testing of aortic endograft to guide clinical practice.J Endovasc Ther. 2022; (15266028221119315)Crossref Scopus (3) Google Scholar Our group has extensive experience of more than 13 years using covered stent grafts for bridging the supra-aortic anastomoses during total arch replacement (SAVSTEB technique), which was acknowledged by the authors in their discussion.8Pichlmaier M. Buech J. Tsilimparis N. Fabry T.G. Joskowiak D. Rustum S. et al.Routine stent bridging to the supraaortic vessels in aortic arch replacement: 10-year-experience.Ann Thorac Surg. 2022; 113: 1491-1497Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Based on this, a recent development of this technology resulted in an innovative custom-made hybrid graft (E-vita OPEN Zero, Jotec, Germany) with inside lying branches.9Pichlmaier M. Tsilimparis N. Hagl C. Peterss S. New anatomical frozen elephant trunk graft for zone 0: endovascular technology reduces invasiveness of open surgery to the max.Eur J Cardiothorac Surg. 2022; 61: 490-492Crossref PubMed Scopus (4) Google Scholar (see also Figure 1) This now avoids having to transect the target vessels. By also transferring the distal anastomosis forward to zone 0, this new graft has allowed us in an early experience to reduce the circulatory arrest time in frozen elephant trunk treatment of acute aortic dissection to as little as 23 minutes. The concept of a one-design-fits-all creates maximum flexibility and requires a minimum selection of grafts to keep on the shelf to deal with a majority of type A dissections. Many different approaches to improve patient outcomes in aortic surgery have been subject to assessment over the years and resulted in the current considerable body of knowledge. Given the available technical options, in situ fenestration, at the most, should be considered a bailout in conventional open aortic arch reconstruction. Total arch replacement with extended branched stented anastomosis frozen elephant trunk repair for type A dissection improves operative outcomeJTCVS TechniquesVol. 17PreviewEmergency surgical repair is the standard treatment for acute aortic dissection type A. However, the surgical risk of total arch replacement remains high. The Viabahn Open Revascularization TEChnique has been used for supra-aortic reconstruction during total arch replacement. This Cleveland Clinic technique is called “branched stented anastomosis frozen elephant trunk repair.” Our total arch replacement with reconstructed extended branched stented anastomosis frozen elephant trunk repair requires no unnecessary cervical artery exposure. Full-Text PDF Open AccessReply: Hybrid aortic arch replacement as innovative treatment option for acute type A aortic dissectionJTCVS TechniquesVol. 18PreviewWe appreciate the insightful commentary of Pichlmaier and colleagues regarding our recent article on the EB-SAFER technique, which allows for simple and fast anastomosis of arch branches.1 In their commentary, they describe their group’s more than 10 years of experience in using covered stent grafts for bridging the supra-aortic anastomoses during total arch replacement (SAVSTEB [The supraaortic vessel anastomosis stent bridging] technique) using VIABAHN (W. L. Gore & Associates, Inc) as the covered stent graft. Full-Text PDF Open Access