Aortic balloon occlusion technique in total arch replacement with frozen elephant trunk after thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) had been increasingly applied in the treatment of thoracic aortic diseases (1). However, there were still some unavoidable early and late complications, including retrograde type A aortic dissection (RTAD), endoleak, paraplegia (2,3). Therefore, some patients had to undergo secondary open arch surgery due to these complications. And total arch replacement (TAR) with frozen elephant trunk (FET) was a preferred surgical strategy in this situation, especially in patients with RTAD (4) and type Ia endoleak (5). However, TAR with FET conventionally required the use of hypothermic circulatory arrest (HCA), which was associated with many adverse complications (6). For patients with prior TEVAR, the arch pathology and anatomy was more complicated, and it took more time to create a distal anastomosis plane. In some condition, the proximal part of the stent was anchored onto the aortic wall, and we had to remove the proximal part of the TEVAR stent by a wire scissor. Therefore, the HCA duration of patients undergoing TAR with FET after TEVAR was much longer than that of patients without prior TEVAR. And it resulted in a higher incidence of complications including paraplegia, renal failure and gastrointestinal dysfunction