title: Distal aortic surgery following arch replacement with a frozen elephant trunk.
abstract: OBJECTIVE
  The frozen elephant trunk technique allows the repair of concomitant aortic arch and proximal descending aortic pathology in a single stage by using a hybrid prosthesis consisting of a vascular graft with a distal stented end. There are patients, however, who will require a second distal operation despite this new technique due to progression of their aortic disease. It has been unclear whether the presence of the stented segment of the hybrid prosthesis results in unexpected technical difficulties or possibly advantages for further vascular reconstruction.
  
  
  METHODS
  Six patients out of our initial cohort of 39 treated with a hybrid prosthesis from 2001 through 2006 have since required an additional distal aortic reconstruction. Two received endoluminal stent grafts, four had extensive open replacements.
  
  
  RESULTS
  There was no 30-day mortality, one patient died on day 133 having been discharged from hospital of an unrelated MRSA septicaemia. Complete thrombosis of the proximally covered aneurysm or the false lumen had occurred in all patients so that the replacements reached from the end of the stented portion of the hybrid prosthesis to the desired distal level. The operative approach proved to be facilitated by the hybrid prosthesis in terms of the necessary exposure and operative trauma. Postoperative recovery was uneventful as related to the hybrid prosthesis with few pulmonary complications and at least comparable to contemporary results for second stage elephant trunk procedures.
  
  
  CONCLUSIONS
  The distal operative replacement of the aorta following a frozen elephant operation is safe and technically feasible. Early experience suggests that there is an advantage as compared to the conventional elephant technique in terms of intraoperative handling and postoperative recovery.
authors.affiliation: Department of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Strasse, D-30625 Hannover, Germany. pichlmaier.maximilian@mh-hannover.de
authors.forename: Maximilian A
authors.initials: MA
authors.lastname: Pichlmaier
authors.forename: Omke E
authors.initials: OE
authors.lastname: Teebken
authors.forename: Nawid
authors.initials: N
authors.lastname: Khaladj
authors.forename: Jürgen
authors.initials: J
authors.lastname: Weidemann
authors.forename: Michael
authors.initials: M
authors.lastname: Galanski
authors.forename: Axel
authors.initials: A
authors.lastname: Haverich
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000601:surgery; D001013:Aorta, Thoracic / Q000601:surgery*; D001014:Aortic Aneurysm / Q000601:surgery; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods*; D018450:Disease Progression; D005240:Feasibility Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D011182:Postoperative Care / Q000379:methods; D012086:Reoperation / Q000379:methods; D015607:Stents; D016896:Treatment Outcome