Comparison between Arch Zones in Modified Frozen Elephant Trunk Procedure for Complex Thoracic Aortic Diseases

Abstract

Introduction The aim of this study is to compare postoperative outcomes and follow-up of two different modifications facilitating surgical technique of frozen elephant trunk (FET) procedure for complex thoracic aortic diseases - zone 0 (fixation with total arch debranching) and zone 3 (fixation with islet-shape arch repair). Methods From May 2012 to December 2018, data were collected from 139 patients who had been treated with FET procedure for complex thoracic aortic diseases. According to Ishimaru arch map, patients with proximal anastomotic site of hybrid graft at zone 0 and zone 3 were grouped as Group A (n=58, 41.7%) and Group B (n=81, 58.3%), respectively. Mean age of study population was 54.7±11.4 years, and 111 patients were male (79.9%). Results In-hospital mortality was observed in 20 (14.4%) patients (n=12, acute type A aortic dissection, and n=4, previous aortic dissection surgery). There was no significant difference between both groups in terms of in-hospital mortality. Four patients from Group A and three patients from Group B had permanent neurological deficit ( P =0.32). Three patients from both groups had transient spinal cord ischemia ( P =0.334). Although mean total perfusion time was longer in Group A, duration of visceral ischemia, when compared with Group B, was shorter ( P <0.001). Five-year survival rate was 82.8% in Group A and 81.5% in Group B ( P =0.876). Conclusion FET procedure is a feasible repair technique in the treatment of complex aortic diseases, providing satisfactory early results. Because of its advantageous aspects, zone 0 fixation with debranching is the preferred technique in our clinic.

Analysing debranching techniques in Frozen Elephant Trunk procedures: a narrative literature review

“…As presented in Table 2 , the comparative studies reported numerically less new PND in patients undergoing debranching with proximalization when compared to patients undergoing conventional FET (0–13% vs. 3.7–17.7%). Three studies showed an impaired neurological outcome after debranching ( 20 - 22 ), one study did not show any differences ( 24 ), and the remaining three studies ( 9 , 10 , 23 ) demonstrated an improved neurological outcome by number, which was statistically significant in one ( 9 ) of the comparative study groups [improvement from 17.7% (conventional) to 0% (debranching and zone 2), P=0.046].…”

“…Over the past two decades the FET technique has evolved as one of the preferred surgical techniques which permits the treatment of extensive aortic arch pathologies including the proximal descending aorta (3,(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)37,(48)(49)(50)(51). Further advancements of this technique were already reported in 2012 when the first cases of debranching techniques with proximalization were described (49).…”

“…Further advancements of this technique were already reported in 2012 when the first cases of debranching techniques with proximalization were described (49). Over the past few years such proximalization techniques gained popularity when compared to the conventional approach, especially for the treatment of ATAAD (9,10,(20)(21)(22)(23)(24). One key for successful aortic arch surgery seems to be the management of the LSA, to facilitate the proximalization and or debranching, and therefore simplify the distal anastomosis of the FET procedure (50,51).…”

“…One of the comparative studies did not report about SCI (24). In 5 of the remaining 6 comparative studies, proximalization showed numerically improved results, ranging between 0 to 5.9% for the debranching cohort, and 0 to 11.8% for the conventional cohort, but the comparison did not reach statistical significance (9,10,20,22,23). One study reported an impaired outcome for the debranching technique (21).…”

The Thoraflex hybrid approach using a zone 0 proximal landing site for first-stage elective treatment of a thoracoabdominal aneurysm

“…Akbulut et al. [ 8 ] identified that unresected aortic tissue, although the island technique wasn’t used here, has a risk of dilatation if there were future endoleaks. The incidence of stroke risk using zone 0 is also debatable.…”