c  2008 Wiley Periodicals, Inc. 659 The Hybrid Stent-Graft Technique: A Solution to Complex Aortic Problems and Lessons Learned John Kokotsakis, M.D., Ph.D., * Panagiotis Misthos, M.D., Ph.D., * Thanos Athanasiou, M.D., Ph.D.,‡ Timotheos Sakellaridis, M.D., * Kostas Neofotistos, M.D.,† Elian Skouteli, M.D., Ph.D., * and Achilleas Lioulias, M.D., Ph.D.† ∗ Second Cardiac Surgical Department, “Evangelismos” General Hospital, Athens, Greece; †Thoracic Surgery Department, “Sismanogleio” General Hospital, Athens, Greece; and ‡Department of Biosurgery and Surgical Technology, Imperial College London, St. Mary’s Hospital, London, UK ABSTRACT Objective: The frozen elephant trunk technique has been recently presented in the literature and has been considered as a novel surgical option for single-stage repair of complex aortic pathology such as combined arch and descending thoracic aortic aneurysms. Patients and methods: The first patient, a 74-year-old male, was admitted severely symptomatic (interscapular pain), with aortic distal arch and proximal descending thoracic aortic aneurysm with a diameter of 6 cm. The second patient, a 72-year- old male, underwent descending aortic aneurysm stent grafting one year ago and was admitted gravely symptomatic (interscapular pain), with aortic arch aneurysm (diameter of 5.7cm) and type I endoleak at the proximal end of the stent. Results: The first patient developed paraplegia after the operation and died three months after the operation due to pneumonia while he was on a rehabilitation program. The second patient’s recovery was uneventful and was discharged on postoperative day nine. Conclusion: This report summarizes our preliminary experience with this technique emphasizing two points: first, it offers the opportunity to manage efficiently complex aortic problems, and second, there is a potential risk of serious complications related to the limited stent sizes available of the device to match the patient’s anatomical characteristics and pathology. doi: 10.1111/j.1540-8191.2008.00672.x (J Card Surg 2008;23:659-663) Complex thoracic aortic disease involving the as- cending aorta, the aortic arch, and the descending aorta still represents a challenge for the cardiothoracic sur- geon. The classic approach for this pathology consists of a two-stage strategy, summing up to mortality up to 40%, with 5% mortality for the waiting period be- tween both surgical stages. 1 One-stage repair can be performed, if required, via a clamshell thoracotomy, but is associated with major surgical trauma and periop- erative morbidity as pulmonary or renal dysfunction, indicating that high-risk patients are not suitable can- didates for this strategy. 2 A novel surgical technique for single-stage repair of combined arch and descend- ing thoracic aortic aneurysms using hybrid prosthesis with a stented and a nonstented end has been recently presented 3-5 This report of two high-risk cases, which were managed with the frozen elephant trunk tech- nique through median sternotomy, summarizes our preliminary experience and lessons learned with this technique. Address for correspondence: Panagiotis Misthos, M.D., Ph.D., 16–18 A Markou Avgeri Street, 15343 Agia Paraskevi, Athens, Greece. Fax: 00302106080107; e-mail: panmisthos@yahoo.gr CASE REPORTS Case 1 The first patient, a 74-year-old male, had a history of aortic root replacement and abdominal aorta replace- ment seven and 10 years ago, respectively, and suf- fered from chronic obstructive pulmonary disease and arterial hypertension. He was admitted severely symp- tomatic (interscapular pain), with aortic distal arch and proximal descending thoracic aortic aneurysm with a diameter of 6 cm (Fig. 1). The patient developed para- plegia after the operation and died three months after the operation due to pneumonia while he was on a re- habilitation program. Case 2 The second patient, a 72-year-old male, underwent descending aortic aneurysm stent grafting one year ago and his medical history included diabetes mel- litus, obesity, and arterial hypertension. He was ad- mitted gravely symptomatic (interscapular pain), with aortic arch aneurysm (diameter of 5.7 cm) and type I endoleak at the proximal end of the stent (Fig. 2). The