Type 1: the modified ET
A 6-8 cm segment of vascular prosthesis is prepared, either cutting the distal end of a tetra-furcated prosthesis (Intergard Woven Aortic Arch, Getinge AB, Göteborg, Sweden), or using a different, straight vascular graft of appropriate diameter (Fig. 1A). This independent segment will become the “elephant trunk” and serve as a landing zone for a subsequent TEVAR. It is inserted in the descending aorta, and its proximal end is anastomosed to the distal aortic stump with a 4.0 polypropylene continuous suture, reinforced with a peri-adventitial strip of Teflon felt (Fig. 1B). The arch prosthesis is then anastomosed to the aortic stump, fitted with the ET-graft, by means of a 3.0 polypropylene continuous suture that is passed through the ET-graft itself, the aortic wall, the Teflon felt strip and the arch graft (Fig. 2). The distal collateral branch of the arch prosthesis is anastomosed end-to end to left subclavian artery origin with a 5.0 polypropylene continuous suture, reinforced with a peri-adventitial strip of Teflon felt. The aortic arch prosthesis is clamped between distal and central branch, distal aorta is de-aired, and the service branch cannulated: lower body perfusion is restarted, while cerebral perfusion is continued on an independent rotor. Once the anastomosis between central branch and left carotid artery is completed, the aortic clamp is repositioned between proximal and central branch, and the intra-luminal cannula is removed. Right-sided cerebral perfusion is obtained through the right axillary artery or the intra-luminal cannula in the brachio-cephalic artery, whilst left-side flow is allowed through the service branch and the arch. The last anastomosis of the supra-aortic vessels between proximal branch and anonymous artery is performed in the same way. Once completed, the aortic clamped is repositioned proximally to first branch origin. The whole body perfusion is therefore achieved through the arch lumen, and proximal repair con be completed as needed.