Aortic remodeling, distal stent‐graft induced new entry and endoleak following frozen elephant trunk: A systematic review and meta‐analysis

Abstract

Background The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one‐step hybrid advantage over conventional techniques. This systematic review and meta‐analysis sought to evaluate controversies regarding the incidence of FET‐related complications, with a focus on aortic remodeling, distal stent‐graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm. Materials and Methods A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted. Results A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% confidence interval [CI] 0.01–0.06, I2 = 78%) and 3% (95% CI 0.01–0.11, I2 = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post‐FET was 7% (95% CI 0.05–0.12, I2 = 89%) while the pooled rate of false lumen thrombosis at the level of stent‐graft was 91% (95% CI 0.75–0.97, I2 = 92%). After subgroup analysis, heterogeneity for distal stent‐graft induced new entry (dSINE) and endoleak resolved among European patients, where Thoraflex Hybrid (THP) and E‐Vita stent‐grafts were used (both I2 = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I2 = 15.1%) and Frozenix stent‐grafts (I2 = 1%). Conclusion Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent‐graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, THP can be considered the primary FET device choice due to its superior results.

Evidence-based frozen elephant trunk practice: a narrative review

“…Interestingly, the authors found no association between dSINE and mid-term survival ( 9 ). A Nakhaei et al meta-analysis ( 15 ) of 5,068 patients found a 2% pooled estimate of dSINE (95% CI: 1–6%, I 2 =78%), and there was no heterogeneity (I 2 =0%) amongst European studies, including those utilising THP and E-Vita stent-grafts. However, the reported incidence across the literature was found to be up to 28%.…”

“…Upon exploring further meta-analyses, across 85 studies encompassing 10,960 patients, Mousavizadeh et al found that the pooled estimate of in-hospital mortality (in 5,569 patients), 30-day mortality (in 6,614 patients), and 1-year mortality (in 1,006 patients) was 7% (95% CI: 5–9%; I 2 =76%), 8% (95% CI: 6–10%; I 2 =76%) and 9% (95% CI: 4–17%; I 2 =90%), respectively ( 23 ). Lastly, a meta-analysis by Nakhaei et al of 5,068 FET patients, reported a relatively lower 5% pooled estimate of in-hospital mortality (95% CI: 4–7%, I 2 =52%) ( 15 ).…”

“…Vessel walls in chronic AD (CAD) tend to be more fragile than those in acute AD (AAD) ( 14 , 15 ). The changes in the aorta’s morphology are possible consequences of increased calcifications within the wall with a thicker and less flexible membrane, which causes the aorta to become less elastic and subsequently impedes remodelling ( 28 ).…”

Thoracoscopic Clipping of Intercostal Artery for Treatment of Type II Endoleak Following Frozen Elephant Trunk Procedure: Case Report

“…1 The preservation of false lumen patency due to endoleak is one of the major causes of reoperations in long-term follow-up. 2,3 Although type II endoleak rarely leads to reoperation on the distal aorta, in some cases it can cause negative aortic remodeling and require reintervention. 4 We present a case of type II endoleak treatment using minimally invasive thoracoscopic clipping of an intercostal artery in a patient with negative aortic remodeling after the FET procedure.…”

How to help aortic dissection survivors with recovery?: A health promotion program based on the comprehensive theory of health behavior change and literature review

“…[4] However, AD survivors still face many challenges, such as postoperative complications, impairment of physical function, decreased quality of life, and psychological trauma. [5][6][7][8] Therefore, the health promotion of AD is one of the important means to help them recover from the disease.…”