title: Minimally invasive approach for aortic arch surgery employing the frozen elephant trunk technique.
abstract: OBJECTIVE
  Classically, repair of extensive thoracic aortic pathologies including the aortic arch and descending aorta required two separate major surgical procedures via full sternotomy and a subsequent left lateral thoracotomy. We describe herein our preliminary institutional experience with minimally invasive single-stage extended thoracic aortic replacement employing the frozen elephant trunk (FET) technique via partial upper sternotomy (PUS) in 14 patients.
  
  
  METHODS
  Between December 2013 and January 2015, 14 consecutive patients with elective indications for FET underwent minimally invasive FET via PUS (PUS-FET) during moderate systemic hypothermia (28°C) and selective antegrade cerebral perfusion (ACP) using the E-vita Open® hybrid prosthesis (Jotec GmbH, Hechingen, Germany). The patients' mean age was 66 ± 6 years, and 9 patients (64%) were male. The arch vessels were reimplanted en bloc in all patients. Clinical data were prospectively entered into our institutional database.
  
  
  RESULTS
  The surgical procedure was successful in all patients with no need for conversion to full sternotomy. An additional David procedure was performed in 1 patient, whereas 2 patients received a concomitant Bentall procedure. There was no perioperative death or 30-day mortality. The mean cardiopulmonary bypass time was 214 ± 35 min, and the myocardial ischaemic time was 125 ± 14 min. The ACP time was 54 ± 9 min, whereas the ventilation time reached 11 ± 4 h. Intensive care unit stay was 2 ± 3 days. Chest tube drainage within the first 24 h was 460 ± 130 ml. None of the 14 patients required re-exploration for bleeding. Patients were discharged after a hospital length of stay of 9 ± 2 days. No postoperative permanent neurological complication occurred. Two patients (14%) experienced temporary delirium with complete resolution of symptoms prior to discharge from the hospital.
  
  
  CONCLUSIONS
  Our preliminary experience suggests that minimally invasive single-stage extended thoracic aortic replacement can safely and reproducibly be performed by employing the concept of PUS-FET.
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt am Main, Germany ali.assayed@gmail.com.
authors.forename: Ali
authors.initials: A
authors.lastname: El-Sayed Ahmad
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt am Main, Germany.
authors.forename: Petar
authors.initials: P
authors.lastname: Risteski
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt am Main, Germany.
authors.forename: Nestoras
authors.initials: N
authors.lastname: Papadopoulos
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt am Main, Germany.
authors.forename: Medhat
authors.initials: M
authors.lastname: Radwan
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt am Main, Germany.
authors.forename: Anton
authors.initials: A
authors.lastname: Moritz
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University Frankfurt/Main, Frankfurt am Main, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Zierer
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000601:surgery*; D001014:Aortic Aneurysm / Q000601:surgery; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods*; D011183:Postoperative Complications; D011446:Prospective Studies; D056346:Sternotomy
keywords: Aortic surgery; Cerebral protection; Frozen elephant trunk technique; Minimally invasive surgery; Partial upper sternotomy