Downstream thoracic endovascular aortic repair following zone 2, 100-mm stent graft frozen elephant trunk implantation

Abstract

OBJECTIVES The aim of this study was to analyse outcomes of downstream thoracic endovascular aortic repair (TEVAR) following the frozen elephant trunk (FET) procedure. METHODS Sixty-six patients underwent downstream TEVAR following the FET procedure to treat thoracic aortic dissections (n = 42, 64%), aneurysms (n = 19, 29%) or penetrating aortic ulcers involving the aortic arch (n = 5, 8%). Patient and outcome characteristics were analysed. RESULTS Downstream TEVAR was performed 7 [interquartile range: 2–18] months after the FET procedure in 39 male (59%) and 27 female (41%) patients aged 68 [interquartile range: 56, 75] years, including 11 patients (17%) with a connective tissue disease. Before TEVAR, cerebrospinal fluid drainage was put in place in 61 patients (92%). Patients were treated with 1 stent graft (n = 28, 42%), 2 stent grafts (n = 37, 56%) or 3 stent grafts (n = 1, 2%). The femoral artery was accessed through surgical cut-down (n = 15, 23%) or percutaneously (n = 49, 74%). One patient (2%) developed a temporary spinal cord injury that resolved spontaneously. No case of permanent spinal cord injury, stroke or death was observed. After 12 [interquartile range: 2–23] months, 15 patients required an additional aortic reintervention (endovascular: n = 6; surgical: n = 9). CONCLUSIONS Downstream TEVAR following the FET procedure is associated with excellent clinical outcomes. We thus maintain that staging thoracic aortic repair—FET and secondary TEVAR—is a very successful and safe strategy. Certain patients might need a tertiary procedure to fix their entire aortic pathology; therefore, they will require long-term continuous follow-up, ideally in a dedicated aortic clinic.

Distal Aortic Failure Following the Frozen Elephant Trunk Procedure for Aortic Dissection

“…On the one hand, using the short (100 mm) version of the prosthesis may potentially reduce the risk for symptomatic spinal cord injuries, but it may also raise the risk for distal aortic failure due to less aortic coverage ( 3 ). This effect may be aggravated by a trend favoring a zone 2 anastomosis, which simplifies the procedure from the surgical perspective, but proximalis further the distal FET stent-graft landing zone ( 8 ).…”

“…These factors require or might have required additional interventional or surgical treatment to prevent the underlying disease from progressing. Distal aortic failure due to dSINE is a relatively common problem following the FET procedure with higher reported incidences compared to conventional TEVAR ( 8 , 21 ). One possible explanation may be a more rigid ring at the distal end of the FET stent-graft when using the Thoraflex device ( 22 ).…”

“…First, we extend the stent-graft part of the FET prosthesis up to the coeliac trunk, usually using two stent-grafts. This approach has so far revealed excellent clinical results with 0% in-hospital mortality or permanent morbidity ( 8 ). Applying this strategy, in case of a third-step open surgical repair, we shift the proximal anastomosis more distally and ensure almost continuous ventilation of the left lung, and keep respiratory complications to a minimum during and after the open replacement of the remaining aortic segments ( 17 ).…”

“…All scans were transferred to imaging software (3mensio, Medical Imaging B.V., Maastricht, The Netherlands) for detailed morphological analysis and measurements of the entire aorta including volume and communication assessment. Follow-up was done at our dedicated aortic outpatient clinic based on our standard follow-up protocol ( 8 ).…”

“…However, many surgeons have changed their perspective on this. There is ample research evidence of the high rate of subsequent aortic reinterventions regardless of the underlying aortic disease ( 6 – 8 ). Nevertheless, the reintervention rate remains an insufficient parameter for assessing the treatment success of proximal aortic procedures.…”