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杉山, 雄紀

渡辺, 元次

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歯周病学

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Kimura, M

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市病・心臓血管外科

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Title
Debranch-First Technique with Zone 0 Elephant Trunk
for Redo Operation of Residual Type B Aortic
Dissection: The Completion of Aortic
Proximalization
Author(s) Inoue, Y
Journal Journal of chest surgery, 57(1): 99-102
URL http://hdl.handle.net/10130/6424
Right
This is an Open Access article distributed under
the terms of the Creative Commons Attribution Non-
Commercial License
(http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted non-commercial use,
distribution, and reproduction in any medium,
provided the original work is properly cited.
Description
99http://www.jchestsurg.org
JCS
Journal of Chest Surgery
Debranch-First Technique with Zone 0 Elephant Trunk for Redo 
Operation of Residual Type B Aortic Dissection: The Completion 
of Aortic Proximalization
Yoshito Inoue, M.D., Ph.D.
Department of Cardiovascular Surgery, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
ARTICLE INFO
Received  July 3, 2023
Revised  August 24, 2023
Accepted  October 20, 2023
Corresponding author  
Yoshito Inoue
Tel  81-47-322-0151
Fax  81-47-322-0151
E-mail  yinoue@tdc.ac.jp
ORCID  
https://orcid.org/0000-0001-8297-4797
†This article was presented at the Asian 
Society for Cardiovascular and Thoracic 
Surgery (ASCVTS) 2023 Busan on June 2, 
2023.
This article presents a straightforward hybrid arch technique for treating residual type B 
aortic dissecting aneurysms following type A repair (replacement of the ascending aorta) 
that employs a frozen elephant trunk (FET) straight vascular prosthesis. The debranch-first 
method involves only cutting and sewing the previous ascending graft, inserting the FET 
from zone 0, and debranching the arch vessels using a trifurcated graft. This technique is 
less invasive as it eliminates the need to manipulate the dissected distal arch aneurysm. 
We successfully applied this technique to 3 patients, with no instances of in-hospital death, 
stroke, or paraplegia. The debranch-first technique, combined with zone-0 FET insertion, 
simplifies the redo repair of residual type B aortic dissection.
Keywords: Type B aortic dissection, Debranch, Frozen elephant trunk, Reoperation, Aor-
tic proximalization
Copyright © 2024, The Korean Society for Thoracic and Cardiovascular Surgery
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/
by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
https://doi.org/10.5090/jcs.23.084
pISSN: 2765-1606   eISSN: 2765-1614
J Chest Surg.  2024;57(1):99-102
Introduction
The proximalization of arch repair to zone 0 with a fro-
zen elephant trunk (FET) improves mortality and reduces 
the incidence of spinal cord injury, stroke, renal injury, and 
visceral ischemia [1]. It is challenging to reoperate a residu-
al dissecting type B aneurysm after ascending aorta re-
placement for type A dissection [2]. To simplify this proce-
dure, we employed a straightforward hybrid approach 
using a FET straight vascular prosthesis. This method in-
volves cutting and sewing the previous ascending graft, in-
serting the FET, and debranching the arch vessels with a 
trifurcated graft. Consequently, aortic proximalization to 
zone 0 is achieved through this debranch-first technique. 
This approach can streamline the reoperation, as it elimi-
nates the need for incision or resection of the residual an-
eurysm or the fragile distal aorta.
Technique
We performed zone 0 arch-first rerouting FET in 3 pa-
tients with residual dissecting aneurysms after ascending 
aorta replacement for type A acute aortic dissection, re-
gardless of the entry tear location (2017–2019; 1 man and 2 
women; age range, 67–83 years). These patients presented 
dilatation of the residual type B aneurysm and required 
surgery (Fig. 1).
The institutional ethics committee granted approval for 
this study (no., 02-010) and waived the requirement for pa-
tient consent.
Median sternotomy was performed, followed by minimal 
dissection of the mediastinum. Cardiopulmonary bypass 
was then established, with inflow through the ascending 
aorta via a branch of the prosthetic graft (1-branched 
J-graft; Japan Lifeline, Tokyo, Japan) equipped with a 
9-mm side-arm (Fig. 2A), and outflow through the right 
atrium. The femoral artery was prepared for temporary 
distal perfusion.
How-to-do-it
100
https://doi.org/10.5090/jcs.23.084
http://www.jchestsurg.org
JCS
We utilized a FET straight vascular graft (FROZENIX; 
Japan Lifeline, Tokyo, Japan) [3]. The size of the FET was 
determined by preoperative computed tomography, and 
was set to be 1.15 times larger than the true lumen size of 
the distal landing zone. The graft length was consistently 
120 mm in all cases, which is equivalent to the length from 
zone 0 to the T6–7 level at the descending aorta. This is 
because an excessively long prosthesis can increase the risk 
of paraplegia [4].
An additional 9-mm side branch was anastomosed to the 
trifurcated graft (Vascutec Gelweave Trifurcate Arch Graft; 
Terumo Co., Tokyo, Japan) to facilitate cerebral perfusion 
(Fig. 2A). The surgical procedure consisted of three steps, 
as shown in Supplementary Video 1. The first step involved 
debranching the arch using a trifurcated graft under deep 
hypothermic circulatory arrest (DHCA) with retrograde 
cerebral perfusion. This is followed by antegrade selective 
cerebral perfusion from the side branch, and the proximal 
stump closure of the arch vessels (Fig. 2B). The second step 
involved making an incision in the ascending aorta graft 
between the previous distal anastomosis and the existing 
side branch. This was followed by FET insertion from zone 
0 to the T7 level of the descending aorta under the guid-
ance of transesophageal echocardiography. The graft-FET 
was then sutured in a single layer under femoral artery sys-
temic perfusion with balloon occlusion of the FET (Fig. 
2C). Subsequent antegrade systemic perfusion from the 
side branch of the ascending aorta graft was performed af-
ter the completion of the anastomosis (Fig. 2D). The third 
and final step involved the anastomosis of the arch graft to 
the side branch of the ascending graft (Fig. 2E), followed 
by weaning from cardiopulmonary bypass.
All patients were treated successfully. There were no in-
stances of in-hospital death, stroke, or paraplegia. In one 
case, an additional endovascular stent graft was performed 
as planned. The durations of circulatory arrest, aortic 
cross-clamping, and cardiopulmonary bypass were 
21.6±2.3 minutes, 90.0±27.1 minutes, and 220.0±7.0 min-
utes, respectively. All patients were monitored for a period 
of 8 to 22 months without any complications.
Discussion
The mortality rate associated with redo surgery for re-
sidual dissecting type B aneurysms following type A repair 
remains high [2]. The debranch-first technique, utilizing 
zone 0 FET, presents a simpler and less invasive alternative 
for treating residual dissecting type B aneurysms com-
pared to the conventional total arch replacement. This is 
A B
Fig. 1. Preoperative (A) and postoperative (B) computed tomography.
Fig. 2. (A) Scheme of ascending aorta inflow through the side branch of the prosthetic graft (red arrow). A new prosthetic graft for inflow 
was sewn to the side branch of the existing graft (prosthetic graft shown in gray). Systemic perfusion started from the side branch (red 
arrow). (B) Arch vessels were anastomosed to trifurcate the graft in end-to-end fashion (black arrows). Cerebral perfusion started from 
the side branch (red arrow). (C) Frozen elephant trunk (FET; yellow) insertion from zone 0 (black arrow), and systemic perfusion from the 
femoral artery (red arrow with black borders) with FET balloon occlusion (green). (D. Single-layer anastomosis of the graft and frozen 
elephant trunk (black arrow). (E) Completion of the hybrid arch by anastomosis of the arch graft to the ascending graft (black arrow).
EDCBA
101
Yoshito Inoue. Debranch-First Redo for Residual Type B Dissection
http://www.jchestsurg.org
JCS
because it negates the need for dissection of periaortic tis-
sues and resection of the aortic arch wall.
Consequently, debranching in zone 0 allows for the 
proximalization of the distal anastomosis to zone 0. This 
provides surgeons with a close view and the ability to ma-
nipulate the aorta in the shallow surgical field, thereby fa-
cilitating safe and simple anastomosis, as well as hemostat-
ic stitches [5]. This process involves only cutting and 
sewing the previous ascending prosthetic graft, in conjunc-
tion with healthy arch vessel anastomosis. Moreover, aortic 
proximalization provides a sufficient proximal landing 
zone, which facilitates additional treatment for descending 
aortic lesions with an endovascular stent graft. It also en-
ables effective thrombo-occlusion of the distal false lumen.
The arch-first strategy under DHCA is our preferred 
strategy for arch repair. This strategy is favored because it 
eliminates the need to spend time establishing selective ce-
rebral perfusion, and it avoids cluttering the surgical field 
with numerous cerebral perfusion catheters. Given that the 
duration of circulatory arrest was a mere 21.6 minutes, 
there was no need for selective cerebral perfusion via cath-
eter. Furthermore, the aortic arch’s shrinkage during 
DHCA simplifies the process of arch vessel anastomosis.
The arch graft utilized in this procedure must be small. 
Given that the dissection of the anterior mediastinum is 
minimal, there is limited space for quadrifurcated arch 
grafts. The size of a trifurcated graft is ideally suited to fit 
the narrow space between the sternum and the ascending 
graft without causing any kinking.
The adequacy of blood flow to the entire brachiocephalic 
system provided by a relatively small debranch graft is a 
matter of debate. Shimizu et al. [6] conducted a study on 
the cerebral blood flow in 16 hybrid arch cases, which in-
volved right subclavian artery to left carotid and subclavi-
an artery bypass, using single-photon emission computed 
tomography. Their conclusion was that the postoperative 
total cerebral blood f low was similar to the preoperative 
f low [6]. Similarly, Goto et al. [7] reported that zone 1-2 
debranching thoracic endovascular aortic repair with an 
extra-anatomical bypass did not affect the total intracrani-
al blood f low. These findings suggest that a trifurcated 
graft can supply sufficient cerebral blood f low in a deb-
ranch-first zone 0 FET procedure.
In conclusion, the debranch-first technique, used in con-
junction with zone 0 FET, effectively completes aortic 
proximalization. This process aids in the reoperation of re-
sidual type B dissecting aneurysms. Furthermore, aortic 
proximalization creates an ample proximal landing zone, 
which simplifies the additional treatment of descending 
aortic lesions with endovascular stent grafts.
Article information
ORCID
Yoshito Inoue: https://orcid.org/0000-0001-8297-4797
Authors contributions
All the work was done by Yoshito Inoue.
Conflict of interest
No potential conflict of interest relevant to this article 
was reported.
Funding
This research did not receive any specific grant from 
funding agencies in the public, commercial, or not-for-
profit sectors.
Supplementary materials
Supplementary materials can be found via https://doi.
org/10.5090/jcs.23.084. Supplementary Video 1. Video of 
the arch-first rerouting and zone 0 frozen elephant trunk 
technique.
References
1. Tan SZ, Lopuszko A, Munir W, Adams B, Bashir M. Aortic proxi-
malization-zone 0 versus zone 2: a concept or true challenge? J Card 
Surg 2021;36:3319-25. https://doi.org/10.1111/jocs.15730
2. Moz M, Misfeld M, Leontyev S, Borger MA, Davierwala P, Mohr 
FW. Aortic arch reoperation in a single centre: early and late results 
in 57 consecutive patients. Eur J Cardiothorac Surg 2013;44:e82-6. 
https://doi.org/10.1093/ejcts/ezt205
3. Furutachi A, Takamatsu M, Nogami E, et al. Early and mid-term out-
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