Intraoperative Detection of Distal True Lumen Collapse and Endovascular Salvage Following Frozen Elephant Trunk Repair for Acute Stanford Type A Intramural Hematoma.

A 76-year-old female Jehovah's Witness presented with an acute Stanford type A intramural hematoma. To avoid transfusion, she underwent ascending aortic replacement with a frozen elephant trunk and total fenestration. During chest closure, she developed sudden bilateral lower-limb ischemia, with regional oxygen saturation declining from 70% to 40%. Transesophageal echocardiography confirmed patency of the frozen elephant trunk and revealed rapid collapse of the distal true lumen beyond the stented segment. Emergent angiography demonstrated severe true-lumen compression. Thoracic endovascular aortic repair with distal bare-metal stent support was performed urgently, restoring flow. Stent deployment began 50 min after ischemia onset, and complete reperfusion was achieved 82 min after onset. The patient was discharged on postoperative day 17 without neurologic or ischemic sequelae.