Simplified frozen elephant trunk technique for combined open and endovascular treatment of extensive aortic diseases

Abstract

OBJECTIVES: This study aims to analyse the impact of a simplified frozen elephant trunk (FET) technique on early outcome. METHODS: Between October 2010 and August 2018, 92 consecutive patients (mean age 64.4 ± 12.2 years) underwent FET surgery. Underlying pathologies were thoracic aneurysm in 35 patients, acute aortic dissection in 25 patients and chronic dissection in 32 patients. Thirty patients underwent a simplified FET technique with deployment of the stent graft in arch zone 2 with an extra-anatomic bypass to the distal left subclavian artery using the third branch of the Thoraflex™ Hybrid Plexus prosthesis via a supraclavicular access during reperfusion. These patients were compared to 62 patients who received the conventional FET procedure, in which a distal anastomosis is performed in arch zone 3. RESULTS: Circulatory arrest (41.7 ± 10.5 vs 76.5 ± 33.0 min; P < 0.001) and antegrade cerebral perfusion times (60.9 ± 13.5 vs 92.1 ± 33.1 min; P < 0.001) were significantly reduced in zone 2 vs zone 3 patients, respectively. The 30-day mortality rate was 3.3% (n = 1) in zone 2 patients vs 17.7% (n = 11) in zone 3 patients (P = 0.75). Stent deployment in zone 2 was associated with significantly reduced rates of postoperative stroke [zone 2: n = 0 (0.0%); zone 3: n = 11 (17.7%), P = 0.046] and recurrent nerve palsy [zone 2: n = 1 (3.3%); zone 3: n = 14 (22.6%), P = 0.020). CONCLUSIONS: Simplifying the FET procedure leads to reduced circulatory arrest and cerebral perfusion times and improves early outcome.

“Proximalization is Advancement”—Zone 3 Frozen Elephant Trunk vs Zone 2 Frozen Elephant Trunk: A Literature Review

“…The Bologna group noted a postoperative SPI to be higher in those who underwent Z-3-FET versus Z-2-FET (7.5% versus 1.4%, respectively), however, this difference was not significant. 24 A similar outcome was reported by Tsagakis et al, 22 where the rate of paraplegia was reduced to half in the Z-2-FET patients, but in their cohort the difference was also deemed not significant. The same team are also noted that the incidence of stroke resulting in paraplegia are 50% lower with Z-2-FET approach.…”

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

“…Preventza et al 6 found that a stent length of 10 cm had a lower risk of spinal cord ischemia, and a stent≥ 15 cm or beyond the T8 should be avoided during the FET operation. Also, the deployment of stent‐graft in Zone 2 can reduce the visceral ischemia time and it is technically easier compared to anastomoses in Zone 3, which can lead to decreased neurological adverse events 25 . We also found in meta‐regression analysis that age was associated with cerebrovascular accidents.…”

“…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.…”

Case-matched Comparison of Cardiovascular Outcome in Loeys-Dietz Syndrome versus Marfan Syndrome

“…Proximal aortic surgery comprised aortic root replacement procedures including the aortic-valve-sparing techniques according to David or to Yacoub, and composite valve grafting procedures according to Bentall comprising aortic root replacement with a biological valve or with a mechanical valve as described previously [39] ( Table 3). Five of these procedures carried out in Marfan syndrome extended into the aortic arch with usage of a frozen elephant trunk procedure in three as described previously [40] (Table 3). For distal aortic repair we employed open techniques with surgical placement of a prosthesis in the isolated thoracic aortic segment, or in the thoracoabdominal segment, or in the abdominal aorta.…”