The frozen elephant trunk technique: impact of proximalization and the four-sites perfusion technique

Abstract

OBJECTIVES To improve organ protection with the frozen elephant trunk (FET) procedure, a so-called four-sites perfusion in combination with proximalization for the distal aortic anastomosis was performed. The impact of these techniques on patient outcome is reported. METHODS Between February 2005 and April 2020, a total of 357 patients underwent the FET procedure for acute (54%) or chronic (22%) aortic dissection or aneurysmal disease (24%). The level of the distal FET anastomosis was defined according to aortic arch zones 0–3. Patients were divided into 3 groups according to the intraoperative perfusion strategy: (i) selective antegrade cerebral perfusion (SACP) alone (N = 96, 2 sites); (ii) SACP plus left subclavian artery or distal aorta (N = 84, 3 sites) and (iii) SACP plus left subclavian artery plus distal aorta (N = 177, 4 sites). Early outcome was addressed by a composite end point: occurrence of either a disabling stroke, a disabling spinal cord injury, extracorporeal circulatory support, kidney dialysis or death within 90 days. RESULTS Preoperative characteristics were similar among the groups. Surgery in group C was characterized by FET proximalization in arch zone ≤2, moderate hypothermia at 28°C and shorter periods of extracorporeal circulation, SACP, hypothermic circulatory arrest and cardioplegic arrest (P < 0.001, respectively). Occurrence of the composite end point was reduced in group C (P = 0.008). The combination of FET proximalization and four-sites perfusion was a protective factor for the composite outcome in multivariable analysis (P = 0.009). The 5-year survival was improved in patients who underwent FET proximalization in zone ≤2 (hazard ratio 0.7, 95% confidence interval 0.4–1.0; P = 0.036). CONCLUSIONS FET proximalization in combination with four-sites perfusion has the potential to improve patient outcomes in terms of survival and major events. Subject collection 120; 161.

NEO E-vita—NEO era!

“…Overall, the 15-year experience with the E-vita Open and Open Plus graft, with all the demonstrated influential strategic innovations, can serve as a reference for comparison with other approaches with different FET devices. The recently reported results, especially with the last 177 patient cohort, are quite satisfying with their 11% 30-day mortality, 1% persisting spinal cord injury, and 7% new stroke occurrence [33].…”

Single-Center Experience With the Thoraflex™ Hybrid Prosthesis: Indications, Implantation Technique and Results

“…Some teams are proving that results for both strategies are comparable, but the bilateral antegrade perfusion allows longer circulatory arrest ( 16 , 17 ). Tsagakis et al proposed four-sites perfusion achieving favorable results ( 18 ). Although very promising results were achieved with this sophisticated method, our institutional experience shows comparable results in a less complex approach.…”

Normothermic frozen elephant trunk: our experience and literature review

“…Proximalization of the distal aortic anastomosis in arch zone ≤2 is a valuable technical advantage of FET repair. It allows the construction of an easier and faster distal anastomosis in a more accessible area avoiding the handling of frail tissue at the distal arch and significantly shortening the circulatory arrest and cardiopulmonary bypass times (38).…”