Correlation of Coagulopathy and Frozen Elephant Trunk Use in Aortic Arch Surgery: A Systematic Review and Meta-analysis

Abstract

Background: The advent of Frozen elephant trunk (FET) for reconstruction of elective and non-elective aortic arch surgery has augmented the treatment of complex aortic pathologies in a single-stage operation. To date, no studies have been focused on the prevalence and predictors of coagulopathy potentiated by FET procedure. Methods: In a systematic review, we searched databases up to June 2020 for studies reporting coagulopathy complications after FET procedure. A proportional meta-analysis was carried out using STATA software (StataCorp, TX, USA). Results: In total, 46 studies including 6313 patients were eligible. The pooled estimation of reoperation for postoperative bleeding was 7% (95% confidence interval [CI] 5 to 8; I2 = 84.73%; reported by 39 studies including 4796 patients). The mean volume of transfused packed blood cells and fresh frozen plasma was 1677 ml (95% CI 1066.4-2287.6) and 1016.5 ml (95% CI 450.7-1582.3). The subgroup by stent type showed a decrease in the heterogeneity (I2 = 0.01%, I2 = 53.95%, I2 = 0.01%, and I2 = 54.41% for Thoraflex® Hybrid, E-vita®, Frozenix®, and Cronus®, respectively). The subgroup by chronicity of operation resulted in less heterogeneity among patients undergoing elective compared to non-elective operation (I2 = 29.22% versus I2 = 80.56% in non-elective). Meta-regression analysis showed that age and male gender significantly impacted on the reoperation for postoperative bleeding. Conclusions: The FET procedure for arch replacement is associated with coagulopathy and the transfusion of blood products. Male, age, and selective choice of FET use were identified as heterogeneity sources of reoperation for postoperative bleeding.

Frozen Elephant Trunk Sizing: A 30,000-Feet Perspective with Thoraflex Hybrid Stent Graft

“…A recent systematic review also highlighted coagulopathy as a major reason for reintervention, although this seemed to affect E-Vita and Cronus devices and not Thoraflex HP and Frozenix. 3…”

“…A recent systematic review also highlighted coagulopathy as a major reason for reintervention, although this seemed to affect E-Vita and Cronus devices and not Thoraflex HP and Frozenix. 3 Indeed, evidence on the relationship between FET stent graft sizing and endoleak risk is varied and requires further investigation. It is worth noting that presently, the vascular domain of EACTS does not mention or recommend an approach to determining appropriate distal stent sizing to tackle endoleak risk, compounding the lack of uniformity from center to center.…”

“…2 Tan et al 2 recently published a comprehensive dataset of clinical outcomes associated with 931 Thoraflex HP implantations in an assessment of its long-term clinical efficacy, and a recent systematic review suggested that Thoraflex HP was associated with lower rates of coagulopathy-related complications than other devices. 3 The surgical approach and perioperative management for TAR with Thoraflex HP have been reported in the literature with some consensus among the aorto-vascular community. [4][5][6] Following median sternotomy and the initiation of cardiopulmonary bypass (CPB), a guidewire may be introduced retrograde into the aortic true lumen (TL) via the femoral artery to aid differentiation of the TL and false lumen (FL) after aortic resection.…”

“…2 Tan et al 2 recently published a comprehensive dataset of clinical outcomes associated with 931 Thoraflex HP implantations in an assessment of its long-term clinical efficacy, and a recent systematic review suggested that Thoraflex HP was associated with lower rates of coagulopathy-related complications than other devices. 3…”

Similarities, differences and unmet needs regarding prosthetic materials in aortic arch replacement using the frozen elephant trunk technique: a review

“…Relevant blood permeability after implantation of the Evita open NEO, a non-sealed prosthesis has been described by different authors (12)(13)(14). In gelatin coated prostheses, no reports could be found about graft permeability during or shortly after the implantation.…”