Incidence of Distal Stent Graft Induced New Entry vs. Aortic Remodeling Associated With Frozen Elephant Trunk

Abstract

BackgroundThe introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortivascular surgery by allowing hybrid repair of complex aortic pathologies in a single step through combining an open surgical approach with an endovascular one. FET has been associated with favorable aortic remodeling, however, its is also associated with development of distal stent graft induced new entry (dSINE) tears postoperatively. The rate of aortic remodeling and the incidence of dSINE have been linked together, in addition, there seems to be a relationship between these two variables and FET insetion length as well as graft size.AimsThe scope of this review is to highlight the rate of aortic remodeling as well the incidence of dSINE associated with different FET devices available commercially. This review also aimed to investigate the relationship between aortic remodeling, dSINE, FET insertion length and FET graft size.MethodsWe conducted a comprehensive literature search using multiple electronic databases including PubMed, Ovid, Scopus and Embase in order to collate all research evidence on the above mentioned variables.ResultsThoraflex™ Hybrid Plexus seems to yield optimum aortic remodeling by promoting maximum false thrombosis as well true lumen expansion. Thoraflex Hybrid™ is also associated with the lowest incidence of dSINE post-FET relative to the other FET devices on the market. Aortic remodeling and dSINE do influence each other and are both linked with FET graft length and size.ConclusionThe FET technique for TAR shows excellent aortic remodeling but is associated with a considerable risk of dSINE development. However, Thoraflex™ Hybrid has demonstrated itself to be the superior FET device on the aortic arch prostheses market. Since aortic remodeling, dSINE, FET insertion length and stent graft size are all interconnect, the choice of FET device length and size must be made with great care for optimum results.

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

“…As expected, without significant changes in aortic diameters the remodeling process is regarded as stable [61,62]. In TAAD, the constant FL antegrade perfusion caused by the intimal entry tears give rise to aneurysmal deteriorations along the aorta, however, if these entry points remain patent after surgical repair, this presents an important risk factor for aortic dilatation and rupture as well as an increase in the need for further distal reintervention [9,63]. Additionally, FL expansion has been shown to be associated with the size and the location of the entry [64].…”

“…Other complications of the FET procedure are, but not limited to, endoleak, spinal cord injury (SCI), renal complications, cerebrovascular events and graft kinking. Yet, it is important to note that the incidence of the above postoperative events is lower with FET compared to conventional arch replacement techniques [9,10,11].…”

“…Several commercial FET HPs exist on the global market, these include Thoraflex Hybrid (Terumo Aortic, Inchinnan, Scotland, UK), E-Vita (JOTEC GmbH, Hechingen, Germany), J Graft Frozenix (Lifeline Co, Ltd, Tokyo, Japan) and Cronus (MicroPort Medical Co, Ltd, Shanghai, China). However, overall evidence in the literature seem to suggest that the Thoraflex Hybrid (or THP) is the superior FET devices on the arch prosthesis market [9,10]. Nevertheless, the literature also describes controversial evidence on the association between the aforementioned commercially-available FET devices and clinical outcomes.…”

Kinking of Frozen Elephant Trunk Hybrid Prostheses: Incidence, Mechanism, and Management

“…As mentioned previously, although the single-step FET procedure does yield excellent results, particularly positive aortic remodeling, there remain several complications associated with it, only one of which is graft kinking. These were addressed in 2 recent studies by Tan et al ( 38 ) and Jubouri et al ( 39 ) who proved the efficacy of FET and the well-established Thoraflex Hybrid as the superior FET HP available commercially.…”

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

“…Nevertheless, the reintervention rate remains an insufficient parameter for assessing the treatment success of proximal aortic procedures. A composite endpoint for these proximal index procedures is thus needed that also covers morphological and clinical aspects after the procedure such as distal stent graft-induced new entries (dSINE), aortic diameter or aortic-related death that determine distal aortic failure ( 9 , 10 ).…”