Type 1: the modified ET
A 6-8 cm segment of vascular prosthesis is prepared, either cutting the
distal end of a tetra-furcated prosthesis (Intergard Woven Aortic Arch,
Getinge AB, Göteborg, Sweden), or using a different, straight vascular
graft of appropriate diameter (Fig. 1A). This independent segment will
become the “elephant trunk” and serve as a landing zone for a
subsequent TEVAR. It is inserted in the descending aorta, and its
proximal end is anastomosed to the distal aortic stump with a 4.0
polypropylene continuous suture, reinforced with a peri-adventitial
strip of Teflon felt (Fig. 1B). The arch prosthesis is then anastomosed
to the aortic stump, fitted with the ET-graft, by means of a 3.0
polypropylene continuous suture that is passed through the ET-graft
itself, the aortic wall, the Teflon felt strip and the arch graft (Fig.
2). The distal collateral branch of the arch prosthesis is anastomosed
end-to end to left subclavian artery origin with a 5.0 polypropylene
continuous suture, reinforced with a peri-adventitial strip of Teflon
felt. The aortic arch prosthesis is clamped between distal and central
branch, distal aorta is de-aired, and the service branch cannulated:
lower body perfusion is restarted, while cerebral perfusion is continued
on an independent rotor. Once the anastomosis between central branch and
left carotid artery is completed, the aortic clamp is repositioned
between proximal and central branch, and the intra-luminal cannula is
removed. Right-sided cerebral perfusion is obtained through the right
axillary artery or the intra-luminal cannula in the brachio-cephalic
artery, whilst left-side flow is allowed through the service branch and
the arch. The last anastomosis of the supra-aortic vessels between
proximal branch and anonymous artery is performed in the same way. Once
completed, the aortic clamped is repositioned proximally to first branch
origin. The whole body perfusion is therefore achieved through the arch
lumen, and proximal repair con be completed as needed.