Open distal anastomosis in the frozen elephant trunk technique: initial experiences and preliminary results of arch zone 2 versus arch zone 3†

Abstract

OBJECTIVES We compared the results of 2 groups of patients who underwent aortic arch replacement with the frozen elephant trunk technique. In the first group, the distal anastomosis was performed in arch zone 2; in the second control group, the distal anastomosis was performed in arch zone 3. METHODS Between January 2007 and April 2018, the frozen elephant trunk technique was used in 282 patients. The median age was 62 years (range 18–83 years), and 233 patients were men (82.6%). Two different frozen elephant trunk prostheses were used: the Jotec E-vita open prosthesis in 167 patients (59.2%) and the Vascutek Thoraflex hybrid prosthesis in 115 patients (40.8%). Patients were divided into 2 groups according to the distal anastomosis site: zone 2 group (69 patients) and zone 3 group (213 patients). The main indications were chronic aortic dissection (n = 164, 58.2%), degenerative aneurysm (n = 72, 25.5%) and acute aortic dissections (n = 45, 16%). RESULTS The overall in-hospital mortality rate was 17%: 20% for the zone 2 group and 16% for the zone 3 group, without significant differences, also in terms of cardiopulmonary bypass and myocardial ischaemia times. However, the visceral ischaemia time was significantly shorter for the zone 2 group, whereas the antegrade selective cerebral perfusion time was significantly longer for the same group. Recurrent laryngeal nerve injury rate was lower in the zone 2 group. The overall postoperative paraplegia rate was 3.5%, whereas the occurrence of permanent neurological dysfunction and dialysis was 9% and 19%, respectively, with no significant differences between the groups. CONCLUSIONS ‘Proximalization’ of the distal anastomosis can be used for arch reconstruction, especially in complex cases such as reoperations or acute aortic dissections. Furthermore, with the aid of branched hybrid grafts, a reduction of the visceral ischaemia time is achieved.

Results of frozen elephant trunk from the international E-vita Open registry

“…Participating centers determined their own surgical protocol, including cannulation technique, temperature management, circulatory arrest technique, perfusion management, myocardial protection, graft sizing, and arch repair technique (e.g., en bloc versus separate branch reimplantation, debranching of the left subclavian, etc.). More detailed descriptions of these techniques can be found in previous publications (8)(9)(10). All patients in the current study underwent open arch repair via median sternotomy under hypothermic circulatory arrest and selective cerebral perfusion.…”

Open total arch replacement with trifurcated graft and frozen elephant trunk

“…Despite surgical and technological advances, total aortic arch replacement with a FET graft remains a challenging procedure, which requires a period of hypothermic circulatory arrest (HCA). Peri-operative mortality and morbidity has improved substantially over the recent years, but still ranges from 4-17% (5)(6)(7)(8)(9)(10).…”

Frozen elephant trunk in total arch replacement: A systematic review and meta‐analysis of outcomes and aortic proximalization

“…A total of 15 studies reported the number of patients implanted the FET stent with the distal anastomosis in Zones 2 or 3, of which only 3 studies including 660 patients compared outcomes in groups by Zone 2 versus Zone 3 25,46,66 . A total of 282 and 378 patients were implanted the FET stent with the distal anastomosis in Zone 2 and Zone 3, respectively.…”

“…Of 64 studies reporting outcomes of patients included in this report 13–76 . The proportions of studies from Asia, Europe, and North America were 54.7%, 31.3%, and 10.9%, respectively.…”