“Buff Cuff” Zone 2 Arch Replacement on a Patient with Prior Type A Dissection

The frozen elephant trunk (FET) technique allows for extensive aortic disease to be treated using a single procedure that combines open surgery with endovascular treatment. This technique has become increasingly popular in the last two decades as it eliminates the need for a second procedure and simplifies treatment for complex aortic pathology. Over the last few years, this technique has evolved to include the branched FET in 2012, and most recently the Buffalo Trunk technique in 2019 (1,2). 

The Buffalo Trunk approach simplifies the hybrid procedure, while minimizing circulatory arrest times and reducing associated comorbidities (1). With the recent availability of branched endovascular thoracic grafts, further modification of aortic procedures may provide improved lifetime management of a patient’s aortic disease. The novel technique presented in this video modifies the Buffalo Trunk procedure by using a shorter stent, named the “Buff Cuff,” which ends proximal to the left subclavian artery. This approach optimizes the future landing zone for thoracic branch endografts and avoids the need for open surgical revascularization of the left subclavian artery.

The Patient

The patient was a forty-two-year-old woman with a medical history of hypertension, stage 3 polycystic kidney disease with chronic kidney disease, and Wolff-Parkinson-White syndrome. She additionally had a confirmed family history of Marfan syndrome and aortopathy. The patient previously suffered a type A aortic dissection with involvement of the root and aortic valve fourteen years prior. This required aortic root replacement with a mechanical aortic valve. Since her primary operation, she underwent aortic surveillance at the comprehensive aortic and vascular center where this procedure was completed. Surveillance imaging demonstrated progressive dilation (>1 cm in five years) of the native ascending aorta and proximal arch with pseudoaneurysmal dilation at the prior aortic anastomosis. Given the patient’s strong personal and family history of aortic catastrophe, surgical intervention was recommended.

The Procedure

The patient underwent a standard redo sternotomy with central cannulation for cardiopulmonary bypass. Cerebral protection during circulatory arrest was achieved with sequential retrograde and antegrade cerebral perfusion at a core temperature of 28°C. A stepwise and detailed description of procedure is provided in the accompanying video.

Conclusions

A novel technique for zone 2 arch replacement was presented. Antegrade deployment of a short endograft optimizes the future landing zone for thoracic branch endografts and avoids the need for open surgical revascularization of the left subclavian artery.

Reference(s)

1. Di Marco, L., Pantaleo, A., Leone, A., Murana, G., Di Bartolomeo, R., & Pacini, D. (2017). The Frozen Elephant Trunk Technique: European Association for Cardio-Thoracic Surgery Position and Bologna Experience. The Korean journal of thoracic and cardiovascular surgery, 50(1), 1–7. https://doi.org/10.5090/kjtcs.2017.50.1.1

2. Eldeiry, M., Aftab, M., Bergeron, E., Pal, J., Cleveland Jr, J. C., Fullerton, D., & Reece, T. B. (2019). The buffalo trunk technique for aortic arch reconstruction. The Annals of Thoracic Surgery, 108(3), 680-686.