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Page 6 of 7 Di Marco et al. Vessel Plus 2020;4:32 I http://dx.doi.org/10.20517/2574-1209.2020.23

this new hybrid prosthesis, we expanded the indications for the FET technique also to type A and B acute
aortic dissections. In this field, with the increased complexity of the cases, we began to “proximalize” the
open distal anastomosis to arch zone 2 with a sensible reduction of the median visceral ischaemia time
(42 min in zone 2 vs. 54 min in zone 3). In our opinion, this could depend on the fact that in the zone 2
group we used more frequently the Thoraflex hybrid prosthesis, allowing an earlier antegrade reperfusion
through its side branch. In addition, zone 2 makes the distal anastomosis easier and faster, especially in
the case of reoperations or emergency cases, so we recommend it. Furthermore, the presence of the side
branches allows to perform an individual arch vessel reconstruction instead of the island technique and to
restart the reperfusion in an antegrade fashion. In fact, we found that achieving an antegrade reperfusion
when possible is preferable, especially in the case of chronic aneurysm. For this reason, when we use
E-vita open, we create a fenestration on the vascular Dacron portion of the graft in order to antegradely
reperfuse through a “Y” line for at least 10 min at the end of the distal anastomosis before reimplanting the
left subclavian artery, which can be performed following discontinuation of the circulatory arrest, during
the reperfusion-phase. In our experience, the Thoraflex hybrid prosthesis was used more frequently in
arch zone 2 for acute dissections. In fact, we believe that a stent graft length of approximately 100 mm is
sufficient to stabilize the intimal flap and to favour expansion of the true lumen in the down-stream aorta,
also because a large intimal tear is often located near the left subclavian artery and can be easily excluded.
The use of a shorter stent graft is also another key factor in order to reduce the rate of spinal cord injuries,
especially in acute aortic dissection. This is because a shorter stent graft covers a shorter segment of the
aorta and therefore fewer intercostal arteries are closed. On the other hand, to achieve a single-stage
treatment in case of chronic aneurysm of the thoracic aorta, the use of a shorter stent graft, such as with
Thoraflex hybrid prosthesis, is not always possible because the distance from zone 2 to the distal end of the
aneurysm does not allow a perfect sealing of the stent. Therefore, in such cases, we suggest to perform the
distal anastomosis in zone 3 or to use a longer stent such as the E-vita open prosthesis (130-160 mm).

DECLARATION
Authors’ contributions
Substantial contribution to the concept and design of the study, data analysis and interpretation: Di Marco L,
Votano D, Pacini D
Data collection, administrative, technical, and material support: Leone A

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflict of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2020.