Defying the Odds: Complete Cerebral Rescue and Neuroprotection after Frozen Elephant Trunk Repair
Igor Villacis Escobar1, Ivana Garrido2, Pamela Balda1, Estefania Balda Desiderio1, Jorge Alonso1, Israel Rosero Basurto1, Xiu Wong1, Ines Baquerizo1, Romina Andrade1, Efrain Paredes1
1Catholic University of Santiago of Guayaquil, 2Omnihospital
Objective:
To illustrate that a structured, physiology-driven neuroprotection protocol can achieve complete cerebral rescue during extensive FET repair in a young patient with acute Stanford type A dissection.
Background:
Cerebral protection during aortic arch surgery remains one of the most formidable challenges in perioperative neurology. Even transient global ischemia can trigger irreversible neuronal loss, cognitive decline, and microstructural white matter injury. Modern neuroprotective strategies deep hypothermia, selective antegrade cerebral perfusion (SACP), and multimodal neuromonitoring aim to maintain perfusion metabolism balance and prevent excitotoxicity during circulatory arrest. The Frozen Elephant Trunk (FET) procedure, though primarily a cardiovascular intervention, presents an extraordinary setting to test the limits of cerebral resilience and neuroprotection.
Design/Methods:
A 38-year-old man with ankylosing spondylitis presented with acute Stanford type A dissection involving the root, arch, and descending thoracic aorta. Surgery included valve-sparing root replacement (David procedure), total arch replacement with FET, and coronary button reimplantation. Deep hypothermic circulatory arrest (20 °C) combined with bilateral SACP and continuous EEG/NIRS neuromonitoring maintained cerebral oxygenation and synaptic stability throughout.
Results:
Intraoperative cerebral perfusion remained stable. Postoperatively, the patient developed refractory cardiogenic shock requiring VA-ECMO for four days, yet neurologic monitoring remained reassuring. MRI demonstrated no infarction or hypoxic injury. The patient achieved full cognitive and motor recovery and remained neurologically intact at three-month follow-up.
Conclusions:
This case exemplifies that integrated, physiology-based neuroprotection can defy expected cerebral compromise even in extreme ischemic scenarios. Deep hypothermia, SACP, and real-time neuromonitoring allowed complete aortic reconstruction while preserving neurologic function. These strategies should be considered standard in high-risk aortic surgery, particularly for young patients where long-term cerebral preservation is critical.
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