"Loss of landing zone"-Stabilizing endovascular treatment solutions in the aortic arch after thoracic endovascular aortic repair.

Addressing proximal complications that arise after endovascular aortic repair for type B aortic dissection, such as type Ia endoleaks, "bird-beaking" of the thoracic endovascular aortic repair (TEVAR) stent, retrograde type A dissection, and postdissection aneurysms, bears considerable complexities. We present a novel and safe method for open arch repair that can ensure a secure and efficient approach for TEVAR complications. The key element of the operative technique is approximating the grafted stent portion to the aortic wall and the arch prosthesis. The technique has successfully been implemented in 11 patients, who received secondary open arch repair from 2019 to 2022 after TEVAR for type B dissection. Our objective is not only to introduce this reliable concept but also to provide a comprehensive demonstration of its advantages and disadvantages compared with currently used open treatment methods and discuss patient outcomes after secondary open arch repair.

Case Report: Incidental finding of an atresia of the inferior vena cava-a challenge for cardiac surgery.

Inferior vena cava atresia is a rare and usually asymptomatic condition. However, when these patients undergo cardiac surgery, it can present an unexpected and challenging situation for the surgeon. Specifically, adequate venous drainage during cardiopulmonary bypass (CPB) is a critical issue here and may require an extension of cannulation strategies. Adequate preoperative diagnostics, ideally with imaging modalities such as CT angiography or MRI, are required for optimal surgical planning. Here, we describe a rare case of thoracic ascending aortic aneurysm with concomitant inferior vena cava atresia that was successfully operated on. With adequate preoperative planning, we were able to perform an operation without unforeseen complications with standard initialization of CPB.

Endovascular Repair With Triple Inner-Branch Endograft for Aberrant Subclavian Artery Aneurysm: A Case Report.

BACKGROUND: Endovascular repair of the thoracic aorta (TEVAR) is the preferred option for the treatment of the distal arch and descending thoracic aorta. Fenestrated and branched TEVAR have become an option to treat pathologies of the aortic arch, avoiding sternotomy and cardiopulmonary arrest as well as total surgical debranching. We describe here the case of a symptomatic patient with an arteria lusoria aneurysm associated with Kommerel diverticulum who underwent total endovascular repair with a triple-branched TEVAR. CASE REPORT: A 66-year-old male patient was treated for a symptomatic arteria lusoria artery associated with a Kommerel diverticulum, resulting in difficulty swallowing and choking. We used a custom-made triple inner-branch endograft (Cook Medical, Bloomington, Indiana) following implantation of a right-sided carotid-subclavian (C-S) bypass. The C-S bypass occluded in the interval time between the 2 procedures and required recanalization and stent-graft placement during the aortic arch procedure. The arteria lusoria was embolized with a vascular plug. No complications occurred and postoperative tomography showed exclusion and thrombosis of the Kommerel diverticulum and perfusion of the supra-aortic vessels. CONCLUSIONS: Treatment of arteria lusoria aneurysms can be performed with total endovascular arch inner-branch repair, avoiding increased risk of morbidity and mortality caused by open or hybrid procedures.

Visceral and renal malperfusion syndromes in acute aortic dissection type A: the fate of the branch vessel.

BACKGROUND: Malperfusion in acute aortic dissection is not uncommonly observed and associated with a highly significant increase in mortality and morbidity. Of the various malperfusion syndromes, visceral and renal involvement is the most challenging in terms of correct and timely diagnosis as well as the choice of management strategy. The aim of this study was to identify the pathology and associated fate of each visceral and renal vessel in acute type A dissections. METHODS: Over a 12-year period, 167 consecutive patients with acute dissection type A extending into the thoracoabdominal aorta were included and radiographic images analyzed with a focus on individual branch vessel pathology and dependent organ perfusion. RESULTS: Sixty-five patients (39%) were diagnosed with radiological signs of malperfusion on the CT Images. Of those, 20% expired during the hospital stay, compared to 8% without malperfusion. The left renal artery was the most frequently affected by dissection (31%) or false lumen supply (28%). False lumen perfusion was more often associated with manifest malperfusion than an extension of the dissection flap into the branch vessel. During the study period, there was no preference of surgical procedure treating the malperfusion. CONCLUSIONS: Malperfusion of the visceral/renal branches of a dissected aorta represents a manifest indicator for postoperative mortality and morbidity. Neither clinical outcome, nor the fate of individual vessels can reliably be predicted prior to proximal reconstruction and thus, surgical strategy cannot generally be defined alone by radiological findings.

Thrombotic microangiopathy following aortic surgery with hypothermic circulatory arrest: a single-centre experience of an underestimated cause of acute renal failure.

OBJECTIVES: Acute kidney injury (AKI) following surgery involving the heart-lung-machine is associated with high mortality and morbidity. In addition to the known mechanisms, thrombotic microangiopathy (TMA) triggered by the dysregulation of complement activation was recently described as another pathophysiological pathway for AKI following aortic surgery. The aim of this retrospective study was to analyse incidence, predictors and outcome in these patients. METHODS: Between January 2018 and September 2019, consecutive patients undergoing aortic surgery requiring hypothermic circulatory arrest were retrospectively reviewed. If suspected, diagnostic algorithm was initiated to identify a TMA and its risk factors, and postoperative outcome parameters were comparably investigated. RESULTS: The incidence of TMA in the analysed cohort (n = 247) was 4.5%. Multivariable logistic regression indicated female gender {odds ratio (OR) 4.905 [95% confidence interval (CI) 1.234-19.495], P = 0.024} and aortic valve replacement [OR 8.886 (95% CI 1.030-76.660), P = 0.047] as independent predictors of TMA, while cardiopulmonary bypass, X-clamp and hypothermic circulatory arrest times showed no statistically significance. TMA resulted in postoperative AKI (82%), neurological disorders (73%) and thrombocytopaenia [31 (interquartile range 25-42) G/l], corresponding to the diagnostic criteria. Operative mortality and morbidity were equal to patients without postoperative TMA, despite a higher incidence of re-exploration for bleeding (27 vs 6%; P = 0.027). After 6 months, survival, laboratory parameters and need for dialysis were comparable between the groups. CONCLUSIONS: TMA is a potential differential diagnosis for the cause of AKI following aortic surgery regardless of the hypothermic circulatory arrest time. Timely diagnosis and appropriate treatment resulted in a comparable outcome concerning mortality and renal function.

Incidence and Surgical Outcomes of Patients With Native and Prosthetic Aortic Valve Endocarditis.

BACKGROUND: The aim of this study was to retrospectively evaluate the incidence and surgical outcomes of patients with native infective endocarditis (IE) and prosthetic aortic valve endocarditis (PVE) over the past decade at a single institution. METHODS: Between January 2005 and December 2015, 289 patients (mean age, 63.3 ± 14.2 years) suffering from native IE (n = 186) and PVE (n = 103) of the aortic valve underwent surgical procedures. Perioperative data were acquired retrospectively for statistical analysis. RESULTS: During the study period the mean incidence of endocarditis increased from 22.0 ± 4.2 (2005-2009) to 29.8 ± 10.1 (2010-2015) cases per year. In-hospital mortality was significantly increased in PVE (22.3%) versus IE (9.1%) patients (P < .001). In elective cases in-hospital mortality between the 2 groups was comparable (2.2% vs 4.6%; P = .288). Multivariate analysis identified urgent surgery (odds ratio [OR], 6.461; 95% CI, 1.941-21.509; P = .002), mitral regurgitation II (OR, 4.230; 95% CI, 1.249-14.331; P = .021), previous homograft operation (OR, 66.096; 95% CI, 2.369-1844.272; P = .0.14), and left ventricular ejection fraction < 40% (OR, 8.267; 95% CI, 1.931-35.388; P = .004) as independent risk factors for in-hospital mortality, whereas pathogen identification by preoperative blood cultures (OR, .228; 95% CI, 0.063-0.817; P = .023) was found to be independently protective. CONCLUSIONS: Surgery for native IE and PVE of the aortic valve may be performed with satisfactorily results at experienced cardiac surgical centers. In comparison PVE patients suffer from a more than twice as high in-hospital mortality, more postoperative complications, and inferior long-term survival. However preoperative identification of causative pathogens in IE and PVE allows for improved in-hospital survival.

Outcomes After Thoracic Endovascular Aortic Repair With Overstenting of the Left Subclavian Artery.

BACKGROUND: Our study aim was to evaluate the impact of left subclavian artery (LSA) flow preservation during thoracic endovascular aortic repair (TEVAR) on outcome. METHODS: Between August 2001 and October 2016, 176 patients (mean age, 61.3 ± 15.8 years) underwent TEVAR with complete LSA coverage. Fifty-five of those patients (31.3%) also underwent LSA revascularization, whereas 121 patients (68.7%) did not. Perioperative data were acquired retrospectively for statistical analysis at the three study institutions. RESULTS: Overall in-hospital and follow-up mortality was 8.5% (n = 15) and 9.1% (n = 16), respectively, including 88 urgent and emergent cases (50%). Stroke (independent of location) and permanent paraplegia rates were 6.8% and 6.3%, respectively, for the entire cohort. Isolated upper-left extremity malperfusion exclusively occurred in 12 (9.9%) of the 121 patients without LSA revascularization. Left-hemispheric stroke was observed four times more often in patients without LSA revascularization and left arm malperfusion (16.7% versus 3.7%, p = 0.095). Multivariate analysis identified no LSA revascularization (odds ratio [OR] 3.779, 95% confidence interval [CI]: 1.096 to 13.029, p = 0.035), two or more endografts (OR 3.814, 95% CI: 1.557 to 9.343, p = 0.003), and coronary artery disease (OR 3.276, 95% CI: 1.262 to 8.507, p = 0.015) as independent risk factors for procedure-related adverse events (left-hemispheric stroke, left arm malperfusion, and permanent paraplegia) after TEVAR with complete LSA overstenting. CONCLUSIONS: Every 10th patient with LSA overstenting and no revascularization experienced left arm malperfusion. No LSA revascularization, extensive aortic coverage with two or more endografts, and coronary artery disease increased the risk of permanent paraplegia, left-hemispheric stroke, and left arm malperfusion. Patients should undergo LSA revascularization to prevent left vertebral artery-associated central neurologic complications and to maintain upper-left extremity perfusion.

Management of Retrograde False Lumen Perfusion After Hybrid Arch Repair in Acute Aortic Dissection.

Patients with acute aortic dissections involving the arch and descending aorta can effectively be treated using the frozen elephant trunk technique. We describe here the novel technique of temporary banding of the descending aorta onto the stent of the hybrid graft in 3 patients who developed unmanageable bleeding from the distal suture line due to retrograde false lumen perfusion and disintegration of the adventitia. Retrograde false lumen perfusion was stopped and therefore bleeding controlled in all patients. Temporal aortic banding represents a novel, feasible, and effective bailout technique for otherwise unmanageable bleeding with fatal outcome in hybrid arch surgery.

Root Replacement for Graft Infection Using an All-Biologic Xenopericardial Conduit.

BACKGROUND AND AIM OF THE STUDY: The management of graft infection following ascending aortic replacement (AAR) and/or aortic valve replacement (AVR) with destruction of the root remains a challenge. Besides technical issues, the choice of graft material is controversial. The study aim was to investigate the initial results of aortic root replacement (ARR) as redo-surgery for infection using the xenopericardial all-biologic conduit (BioIntegral) as an alternative to a homograft or prosthetic material. METHODS: Between February 2013 and January 2015, a total of 18 consecutive patients (16 males, two females; mean age 61 ± 14 years) were reoperated on for infection at a mean of 55 ± 61 months (range: 3 to 219 months) following previous AVR (n = 6), supracoronary aortic replacement (SAR, n = 2), AVR + SAR (n = 1), root replacement (n = 7), and root reconstruction (n = 2). Two patients (11%) had undergone more than one previous cardiac operation. Signs of infection were seen on computed tomography (CT) scanning in 17 patients (94%). Additional 18F-FDG PET-CT was performed in nine patients (50%). RESULTS: The cardiopulmonary bypass and crossclamp were 289 ± 77 min and 187 ± 59 min, respectively. Hypothermic circulatory arrest (HCA) + selective antegrade cerebral perfusion (SACP) was necessary in nine patients (50%) and concomitant procedures in 11 (61%). Postcardiotomy extracorporeal life support (ECLS) was necessary in five patients, and renal replacement therapy in eight. One patient died intraoperatively, and the overall 30-day mortality was 22% (n = 4) secondary to multi-organ failure. Risk factors for mortality were myocardial failure requiring ECLS (p = 0.02) and the need for root replacement following previous isolated AVR (p = 0.05). The mean follow up was 12 ± 5 months. Early graft reinfection occurred in one patient (6%), and another presented with pleural empyema without evidence of persisting conduit infection. Thus, freedom from graft reinfection was 94%. No case of structural valve deterioration was seen. CONCLUSIONS: Aortic root replacement using a xenopericardial conduit in patients with graft infection is technically feasible. Hemodynamics and surgical handling are comparable to that of homografts, but the off-the-shelf availability favors this approach. Mortality was substantial but comparable to that of other series and grafts, with low reinfection rates. Long-term outcome regarding the eradication of infection and durability of the graft remains to be demonstrated.

Ascending Aortic Disease is Associated with Earlier Menopause and Shorter Reproductive Life Span.

OBJECTIVES: The incidence of cardiovascular morbidity and mortality in premenopausal women is comparatively low, but increases sharply after menopause. The principal aim of this study was to determine whether women with ascending aortic disease (AAD) have a different reproductive history from that of an age-matched control group. METHODS: In this retrospective study, women who had undergone ascending aortic aneurysm (AscAA) repair between 2000 and 2010 were asked to complete a questionnaire concerning risk factors and reproductive history. Data from 142 women with AAD were evaluated, and a subgroup (n = 64) with AscAA ≥5 cm was analyzed and compared to an age-matched random control group without known aortic diseases. RESULTS: Almost all women were menopausal at the time of the questionnaire (98.4% vs. 90.6%, AscAA ≥5 cm subcohort vs. control, p = 0.12) and all subjects presented with a comparable age of menarche (13.7 ± 2.6 years vs. 14.2 ± 1.8 years, AscAA ≥5 cm subcohort vs. control, log-rank 0.04, p = 0.84). However, mean menopausal age was significantly lower in the case subcohort than in controls (48.1 ± 4.8 years vs. 50.6 ± 5.8 years, AscAA ≥5 cm subcohort vs. control, log-rank 8.35, p = 0.004), and reproductive life span was correspondingly shorter (34.2 ± 5.2 years vs. 36.2 ± 5.7 years, p = 0.04). Furthermore, hypertension was more prevalent in women with AscAA ≥5 cm compared to controls (89.1% vs. 61.9%, AscAA ≥5 cm subcohort vs. control, p < 0.001). CONCLUSION: Women who experience menopause at an earlier age than the regional mean could profit from screening for cardiovascular disease in general and particularly for AAD. Screening would enable early aneurysm detection and could, therefore, reduce morbidity and mortality.

Immediate, Early and Late Failure after Transcatheter Aortic Valve Implantation: How to Deal with the Inoperable?

BACKGROUND: Currently, the use of transcatheter aortic valve implantation (TAVI) is constantly increasing, whilst cardiosurgical back-up varies substantially. Besides immediate conversion to surgical aortic valve replacement (SAVR) for periprocedural complications, SAVR for TAV failure may be necessary within the early or late post-implant course. The etiology, incidence, risk-stratification, management and outcome for both scenarios are largely unclear. The study aim was to provide details of the authors' experience of SAVR after the failure of TAVI at a single institution. METHODS: Nineteen patients (14 males, five females) underwent SAVR after TAVI at the authors' institution between June 2008 and December 2015. The patients' initial EuroSCORE II was 8.54 ± 9.81. In eight cases (42%; 50% transfemoral) an immediate conversion was necessary due to paravalvular leakage and insufficiency (n = 1), valve-malpositioning (n = 1), valve dislocation (n = 3), valve-trapping in mitral chordae (n = 1), and annular rupture (n = 2). The 50% transfemoral EuroSCORE II was 19.06 ± 8.61. In 11 patients transcatheter valve failure occurred at a mean of 18 ± 17 months after TAVI (two patients with structural valve failure and one with severe paravalvular leakage, seven with prosthetic valve endocarditis, and one patient with aortic aneurysm); the mean EuroSCORE II was 13.42 ± 13.06. RESULTS: For immediate conversion, the cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 104 ± 40 min and 60 ± 16 min, respectively. Concomitant procedures were necessary in two patients, one patient required hypothermic circulatory arrest (HCA) and one died intraoperatively. For early and late failure, the CPB and cross-clamp times were 115 ± 32 min and 82 ± 20 min, respectively. HCA was necessary in one patient, and concomitant procedures in seven patients. The 30-day survival was 63% for immediate SAVR and 100% for early and late SAVR, even though one more patient died on postoperative day 31 after immediate SAVR. Besides, the longest follow up periods were 29 ± 15 months and 19 ± 14 months for immediate and early/late failure, respectively. In both groups, one patient died from cardiovascular-related causes, and one from non-valve-related causes. CONCLUSIONS: SAVR after previous TAVI will become increasingly relevant. Due to the increasing use of TAVI in medium- or lower-risk patients, adequate strategies must be established since, in comparison to multimorbid patients, not taking action in these patients is not an option. Due to potentially high-risk patients and unique technical implications, SAVR after TAVI differs from conventional (redo) AVR. Under optimal conditions, acceptable survival rates can be achieved, but effective interdisciplinary approaches are essential.

Two-stage multilevel en bloc spondylectomy with resection and replacement of the aorta.

OBJECTIVE: We report a case of multilevel spondylectomy in which resection and replacement of the adjacent aorta were done. Although spondylectomy is nowadays an established technique, no report on a combined aortic resection and replacement has been reported so far. METHODS: The case of a 43-year-old man with a primary chondrosarcoma of the thoracic spine is presented. The local pathology necessitated resection of the aorta. We did a two-stage procedure with resection and replacement of the aorta using a heart-lung machine followed by secondary tumor resection and spinal reconstruction. RESULTS: The procedure was successful. A tumor-free margin was achieved. The patient is free of disease 48 months after surgery. CONCLUSION: En bloc spondylectomy in combination with aortic resection is feasible and might expand the possibility of producing tumor-free margins in special situations.

Unilateral hypertrophic osteoarthropathy in a patient with a vascular graft infection.

We report a patient who presented with high fever; a unilateral, palpable tender swelling along the right shin; and effusions in knee and ankle joints leading to the diagnosis of hypertrophic osteoarthropathy (HOA). The diagnostic workup revealed an infected vascular graft that had been implanted 2 years before because of a ruptured infrarenal aortic aneurysm as the cause of HOA. The patient was treated successfully with antibiotics and surgically replacing the infected graft. Hypertrophic osteoarthritis is a clinical entity characterized by digital clubbing, periostitis, and synovial effusions. Primary and secondary forms have been described. Secondary HOA develops as a consequence of various diseases, mainly intrathoracic malignancies. Vascular graft infection, as reported here, is a rare cause of HOA. This case underlines the typical clinical features of HOA and the importance of a prompt and comprehensive diagnostic workup in cases of HOA. Our aim is to sharpen the awareness of its multiple underlying causes. Unilateral HOA is a rare but strong and important sign of infection of vascular prosthesis.

Implantable defibrillator therapy for ventricular tachyarrhythmia in left ventricular assist device patients.

AIMS: Ventricular arrhythmias (VA) occur frequently after permanent left ventricular assist device (LVAD) implantation in end stage heart failure. Left ventricular assist device patients require rhythm control in contrast to patients with biventricular support. However, the rationale for implantable cardioverter-defibrillator (ICD) utilization in LVAD patients remains unclear. This study investigated the safety and efficacy of primary prevention ICD therapy and the rate of appropriate ICD interventions in LVAD patients. METHODS AND RESULTS: We prospectively collected data from patients receiving LVADs. Patients without previous ICD received an ICD after LVAD implantation for primary prevention. Sixty-one patients with LVAD and ICD were followed prospectively for 365 +/- 321 days. Nine patients died from thromboembolism or haemorrhage. Overall, the rate of appropriate ICD interventions was 34%, mostly for treatment of monomorphic VT in 52%, polymorphic VT in 13%, and VF in 35%. Seventy-one percent of VA were terminated by overdrive pacing, 29% by shock. Patients with a history of VA before LVAD implantation had a significantly higher 1-year rate for ICD therapy compared with LVAD patients with a primary prevention ICD indication LVAD patients (50 vs. 24%). Similarly, patients with non-ischaemic cardiomyopathy had a significantly higher risk for ICD therapy than patients with ischaemic heart disease (50 vs. 22%). CONCLUSION: Implantable cardioverter-defibrillator therapy is safe and effective in LVAD patients. Ventricular arrhythmias leading to ICD intervention occur frequently in 34% of LVAD patients after 1 year, with large variations depending on the underlying cardiac disease and previous arrhythmia history. Primary prevention ICD indication after LVAD implantation yields high rates of ICD intervention. A history of previous VA strongly predicts future use of ICD treatment after LVAD implantation.

Surgical treatment of a thoracoabdominal aneurysm in Cogan's syndrome.

Cogan's syndrome is a rare systemic disease which occurs predominantly in children and young adults. It was originally described as the combination of interstitial keratitis and audiovestibular disturbance. The nonspecific symptoms of the patients can be associated with numerous of systemic manifestations and, most characteristic, cardiovascular involvement. It affects large vessels (Takayasu-like) and medium size (polyarteritis nodosa-like) vessels. Here a case of extensive thoracoabdominal aortic replacement in a 28-year-old woman with Cogan's syndrome due to the symptomatic aortic aneurysm is described.

Morphology of current of injury does not predict long term active fixation ICD lead performance.

BACKGROUND: Currents of injury (COI) have been associated with improved lead performance during perioperative measurements in pacemaker and ICD implants. Their relevance on long term lead stability remains unclear. METHODS: Unipolar signals were recorded immediately after active fixation ICD lead positioning, blinded to the implanting surgeon. Signals were assigned to prespecified COI types by two independent investigators. Sensing, pacing as well as changes requiring surgical intervention were prospectively investigated for 3 months. RESULTS: 105 consecutive ICD lead implants were studied. All could be assigned to a particular COI with 48 type 1, 43 type 2 and 14 type 3 signals. Pacing impedance at implant was 703.8+/-151.6 Ohm with a significant COI independent drop within the first week. Sensing was 10.6mV+/- 3.7mV and pacing threshold at implant was 0.8+/-0.3mV at 0.5ms at implant. There was no significant difference between COI groups at implant and during a 3 months follow up regarding sensing, pacing nor surgical revisions. CONCLUSIONS: Three distinct patterns of unipolar endocardial potentials were observed in active fixation ICD lead implant, but COI morphology did not predict lead performance after 3 months.

Distal aortic surgery following arch replacement with a frozen elephant trunk.

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.

High resolution computed tomography imaging for individualized allograft replacement of an infected Dacron aortic arch prosthesis.

We report on the case of a young woman with a history of intravenous drug abuse and the development of an infection of a prosthetic supracoronary-, total arch and partial descending aortic allograft prosthesis following acute aortic dissection type Stanford-A two years previously. For surgical treatment we implanted an allograft prosthesis obtained from a local tissue bank. Particular variations in this setting and in comparison to conventional surgical planning were that high resolution computed tomography imaging was applied to determine and subsequently order the optimal allograft prosthesis in this individual patient and anatomical situation.

The frozen elephant trunk technique.

The so-called 'frozen elephant trunk' technique is adapted from the classical elephant trunk technique first described by H.G. Borst in 1983 and allows the repair of concomitant aortic arch and proximal descending aortic aneurysms in a single stage. A 'hybrid' vascular graft consisting of a conventional tube graft with an endovascular stented graft at the distal end is utilised to achieve a blood-tight seal in the descending aorta that cannot easily be accessed directly from an anterior approach. Thus, the concept of a traditional elephant trunk, otherwise completed with a secondary endovascular or surgical procedure, is achieved in one single step. First intra- and postoperative results of this technique in terms of successful exclusion of the proximal descending aortic aneurysm are good and following the learning curve, the prolongation of circulatory arrest and cerebral perfusion, as compared to the traditional elephant trunk procedure, is within minutes and thus acceptable. Currently all patients with thoracic aneurysms extending from the arch beyond the left subclavian artery are evaluated for this treatment at our institution. Furthermore, acute aortic dissections (type A and B) are an area of intensive clinical evaluation at present.