Institutional practice in sizing of the hybrid prosthesis in frozen elephant trunk surgery

Journal of Cardiac Surgery

Jubouri

et al. 2022

Self Cite

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.

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

Nakhaei

Journal of Cardiac Surgery

Jubouri

et al. 2022

Self Cite

“…On the other hand, stent-graft undersizing may cause endoleak, which also hinders the remodeling process. Therefore, graft oversizing by only 10-15% is recommended [75,84,85]. However, the optimal graft length remains debatable as longer grafts have been shown to promote improved remodeling and lower dSINE occurrence but increasing the risk of SCI [9].…”

Section: Discussionmentioning

confidence: 99%

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

Jubouri

Nakhaei

et al. 2022

Preprint

Self Cite

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% CI 0.01-0.06, I = 78%) and 3% (95% CI 0.01-0.11, I = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I = 89%) whilst the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I = 92%). After subgroup analysis, heterogeneity for dSINE and endoleak resolved among European patients, where Thoraflex Hybrid and E-Vita stent-grafts were used (both I = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I = 15.1%) and Frozenix stent grafts (I = 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, Thoraflex Hybrid can be considered the primary FET device choice due to its superior results.

“…This has been examined at length in a previous study. 10 Unlike in ATAAD, FL thrombosis is not always desirable—it is common for the blood supply to aortic branches (e.g., intercostal or renal arteries) to be derived from the FL. 8 Preoperative assessment of the origins of such vessels from the FL, and distal reentries thereto, is an essential step in the selection of graft diameter and length for CTAAD.…”

Section: Discussionmentioning

confidence: 99%

“…Sizing exerts considerable influence on overall surgical success as well as short- and long-term clinical outcomes: Idhrees et al 9 argue that narrower stent grafts make adequate sealing challenging, while wider stent grafts potentiate improper stent expansion, crumbling, intimal injury, and distal stent-induced new entry (dSINE) tears. 10 Similarly, shorter graft lengths may not fully cover the intimal entry tear, while longer grafts have been suggested to increase paraplegia risk. 9 Considering the significance of graft sizing toward patient outcomes in FET procedures, an appreciation of the heterogeneity in graft sizing practices is warranted.…”

Section: Introductionmentioning

confidence: 99%

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

Tan

Idhrees²,

2022

Aorta (Stamford)

There is currently no standard, evidence-based approach for sizing the Thoraflex Hybrid prosthesis in frozen elephant trunk surgery. We present regional data on 906 Thoraflex grafts implanted in the United Kingdom between December 2012 and August 2021 to emphasize the heterogeneity in sizing practices and evaluate the impact this may have on clinical outcomes. Highlighting this heterogeneity will help develop an evidence-based approach to prosthesis sizing, thereby aiding decision-making for arch repair.