Customized T-NEXT Thoraflex graft for staged hybrid surgery of the aortic organ

Berretta et al. describe a 3-stage hybrid procedure for an extensive Crawford type II thoraco-abdominal aneurysm in a 75-year-old man. They used a customized T-NEXT graft (Terumo Aortic, Vascutek Ltd., Inchinan, UK) for frozen elephant trunk (FET) for arch and descending thoracic aorta, branched endovascular repair (BEVAR) of the thoracoabdominal aortic aneurysm, and subsequent endovascular repair (EVAR) of the infrarenal aorta (1). The authors need to be congratulated for the complex interventions involving the entire length of the aortic organ in a very elderly man.

The case highlights three important points:

• The increasing complexity of interventions for the length of the aortic organ;
• Complimentary interplay between open, endovascular and hybrid approaches, especially with the provision of a landing zone distal to the arch with FET;
• Evolution of the device iterations for hybrid open stent grafts in response to identified challenges.

Could a staged procedure have been avoided here? The staged procedure was an imperative and not just optional. The management of the ascending aorta and arch necessitated a sternotomy. FET provided a landing zone for subsequent EVARs (BEVAR and EVAR for the thoracoabdominal aorta). Conventionally, without the landing zone provided by FET, these would have needed a very morbid open thoracoabdominal resection. This may have carried a prohibitively high risk for this elderly patient. The staged (endovascular) repair decreases the morbidity and mortality associated with an extensive one-stage thoracoabdominal resection, especially in the elderly.

The need for customization of the Thoraflex graft has been felt for a long time, as ‘one size fits all’ does not work for different body habitus and arch types. The conventional graft causes excessive proximalization of the ascending aortic anastomosis and graft overcrowding. A more distal zone 2 anastomosis or branched graft configurations may not always be possible to avoid this. T-NEXT would be more suitable in patients with short stature, small necks, and low-lying arches where proximalization is difficult and hampers further work on the root. Excessive proximalization (especially under tension) in acutely angulated and gothic arches has been associated with kinking of the Thoraflex graft in the mid arch flexure, with life-threatening distal malperfusion and graft thromboembolism (2).

Terumo has been able to offer custom-designed hybrid Thoraflex solutions (not in the USA) for some time now in close collaboration with surgeons for tailored solutions for arches in individual patients (3). The Eusanio group (Ancona, Italy) had previously described the T-NEXT configured Thoraflex graft to circumvent some of the issues with the normal configuration (4). This, of course, is associated with significant delays of up to 6–8 weeks in initial designing and customization, prototype preparation for approval, and then the final product to be delivered. At present, Terumo has been able to offer this only from their factory in Scotland, and associated timelines and logistics of communications, supply chains, and delivery may not work well with distribution areas outside of the UK/Europe. Likewise, customization is not feasible for urgent/ emergency operations with rapid growth, risk of rupture or dissection in dissected or leaking aortas. T-NEXT may therefore only be suitable for carefully planned elective cases where radiological imaging is available well in time for designers to plan and customize the graft. Usually dummy prototypes with varying dimensions may be required for the surgeon to actually ’see, feel and measure’ before a final version is prepared and delivered in sterile packaging for actual use at surgery.

A revised iteration of the original Thoraflex design has been necessary for a long time. The normal Thoraflex configuration adds a length of at least 60 mm proximal to the cuff anastomosis with a serial longitudinal placement of the arch grafts (12 mm, 8 mm, 10 mm bases with intervening 10 mm regions). This crowds the proximal ascending aortic anastomosis further towards the root—at times leaving no proximal space. The T-NEXT reconfigures the placement of the three arch side grafts (as two side branches with a Y-graft for left common carotid and left subclavian) circumferentially to avoid the proximal displacement of the anastomosis on the ascending aorta by 40–50 mm. This also has a number of other advantages in reducing the length and angulation of the arch side branches (making access easier due to a straighter course for future percutaneous wire interventions), reducing crowding of the grafts with in the confined space in the neck and simplifying the distal anastomosis on the head/neck vessels with reduced periods of circulatory arrest. A redo entry for a later stage aortic root intervention is also easier by avoiding injury to grafts.

Does the reduced proximalization of the aortic anastomosis with T-NEXT make future interventions on the root easier as suggested by the authors? It would seem so, with greater distance of the anastomosis from the sino-tubular junction and less crowding of grafts. Additional branched graft strategies used without T-NEXT increase complexity and duration due to ‘on the table’ planning while on cardiopulmonary bypass/circulatory arrest. There are also additional risks of bleeding from a greater number of anastomoses, errors with graft lengths, and potential for kinking. A customized graft with prior planning saves time and reduces chances of failure with ‘on the table’ planning.

To summarize, the reported case shows newer approaches to surgery of the aortic organ by staging the procedures, judicious use of complex open, hybrid and endovascular stent grafts and advances in the stent graft design to aid placement and improve success with re-interventions.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article has undergone external peer review.

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Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0025/coif). The author has no conflicts of interest to declare.

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References

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4. Di Eusanio M, Gatta E. T-next: a new custom-made Thoraflex graft to simplify proximal and distal aortic reinterventions. Eur J Cardiothorac Surg 2023;63:ezad232. [Crossref] [PubMed]