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. 2025 Jun 25:33:38-50.
doi: 10.1016/j.xjtc.2025.06.010. eCollection 2025 Oct.

Proximalization of the distal anastomosis in frozen elephant trunk surgery

Philipp Pfeiffer  1 , Karen Wittemann  1 , Edoardo Zancanaro  1 , Vanessa Buchholz  1 , Leon Mattern  1 , Chris Probst  1 , Franz Masseli  1 , Ahmed Ghazy  1 , Hendrik Treede  1 , Daniel-Sebastian Dohle  1
Affiliations

Proximalization of the distal anastomosis in frozen elephant trunk surgery

Philipp Pfeiffer et al. JTCVS Tech. .

Abstract

Background: The frozen elephant trunk (FET) technique is frequently used in aortic arch diseases. Proximalization of the distal anastomosis from zone 3 to zone 2 results in shorter distal ischemia times and improved outcomes. This study assessed the impact of performing distal anastomoses progressively more proximally.

Methods: A total of 243 patients treated between March 2016 and December 2023 were identified using our institutional database, and relevant data were analyzed retrospectively. The patients were stratified according to the distal anastomosis zone, and perioperative and outcome variables were compared. A subgroup analysis was performed accordingly for patients with acute aortic dissections.

Results: Most of the 243 included patients (66%) were treated for acute dissection, followed by chronic dissection (24%) and thoracic aortic aneurysms (10%). The patients' mean age was 62.5 ± 10.8 years, and 175 patients (72%) were male. The distal ischemia time was significantly reduced with the more proximal anastomoses: 24.5 minutes for zone 0 (69 patients), 37.4 minutes for zone 1 (18 patients), 30.4 minutes for zone 2 (145 patients), and 38.7 minutes for zone 3 (11 patients); P < .001. A longer cross-clamping time in zone 0 was explained by the higher number of root procedures, while other outcome parameters showed no significant differences. These same significant differences also were present in the acute dissection subgroup. In a separate analysis, a shorter duration of distal ischemia correlated with improved long-term survival (P = .002).

Conclusions: The FET technique with distal anastomosis in zone 2 is a reliable technique that produces good results. Proximalization of the distal anastomosis to zone 0 significantly reduces the ischemic burden and simplifies the procedure.

Keywords: aortic arch surgery; aortic dissection; thoracic aortic aneurysm; zone 0.

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Conflict of interest statement

Dr Dohle served as a consultant to Artivion during the study period. 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.

Figures

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Graphical abstract
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A shorter duration of distal ischemia significantly improved long-term survival.
Figure 1
Figure 1
A, Zone 3, reimplantation of supra-aortic vessels using the island technique. B, Zone 2, reimplantation of innominate artery and left common carotid artery using the island technique, with extra-anatomic bypass of the left subclavian artery. C, Zone 0, innominate artery and left common carotid artery are supplied via branches of a trifurcate-style prosthesis, with extra-anatomic bypass of the left subclavian artery and a longer stent graft. D, Zone 0, innominate artery and left common carotid artery are separately replaced and implanted into a straight prosthesis, with extra-anatomic bypass of the left subclavian artery and a shorter stent graft.
Figure 2
Figure 2
Long-term survival stratified by the zone of distal anastomosis. Shaded area indicates 95% confidence interval.
Figure 3
Figure 3
Long-term survival stratified by the median duration of distal ischemia. Shaded area indicates 95% confidence interval.
See this image and copyright information in PMC

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