Zone proximalization in frozen elephant trunk: what is the optimal zone for open intervention? A systematic review and meta-analysis

Ansari

Zaqout

et al. 2022

Preprint

Self Cite

Background: Acute type A aortic dissection (ATAAD) is a life-threatening medical condition requiring urgent surgical attention. It is estimated that 50% of ATAAD die within 24 hours of onset, with the mortality rate is increasing by 1-2% every additional hour without prompt intervention. A variety of ATAAD surgical repair techniques exist which has sparked controversy within the literature, with the main two strategies being proximal aortic replacement (PAR) and total arch replacement (TAR). Nevertheless, the question of which of these two strategies if the more optimal is still debatable. Aims: This commentary aims to discuss the recent study by Sa and colleagues which presents a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing aggressive (TAR) and conservative (PAR) approaches to manage ATAAD patients. Methods: A comprehensive literature search was performed using multiple electronic databases including PubMed, Ovid, Google Scholar, EMBASE and Scopus in order to collate the relevant research evidence. Results: The more aggressive TAR approach for treating ATAAD seems to yield more favourable results including more optimal long-term survival as well as a lower need for reoperation. The frozen elephant trunk (FET) technique can be considered the mainstay TAR technique. Conclusion: It is valid to conclude that TAR with FET is the superior strategy for managing ATAAD patients.

Section: Coi and Funding: Nonementioning

confidence: 99%

Total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Aggressive versus conservative

Ansari

Zaqout

et al. 2022

Preprint

Self Cite

“…The management of complex pathologies of the thoracic aorta have always presented a challenge to surgeons due to the high associated risk of morbidity and mortality. The introduction of frozen elephant trunk (FET) technique facilitated total arch replacement (TAR) procedures by shortening the aortic occlusion time for proximal anastomosis, providing the opportunity of treating complex aorta pathologies in a single‐step procedure, or by offering a more optimal landing zone for secondary endovascular intervention if needed 1 . Due to its hybrid approach, FET has gained great popularity in the field of aortovascular surgery, and since its introduction, it has become the mainstay technique for TAR in a wide spectrum of complex thoracic aortic diseases.…”

Section: Introductionmentioning

confidence: 99%

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

Nakhaei

Bashir

Journal of Cardiac Surgery

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.

“…The management of complex pathologies of the thoracic aorta have always presented a challenge to surgeons due to the high associated risk of morbidity and mortality. The introduction of frozen elephant trunk (FET) technique facilitated total arch replacement (TAR) procedures by shortening the aortic occlusion time for proximal anastomosis, providing the opportunity of treating complex aorta pathologies in a singlestep procedure, or by offering a more optimal landing zone for secondary endovascular intervention if needed [1]. Due to its hybrid approach, FET has gained great popularity in the field of aortovascular surgery, and since its introduction, it has become the mainstay technique for TAR in a wide spectrum of complex thoracic aortic diseases.…”

Section: Introductionmentioning

confidence: 99%

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

Nakhaei

Bashir

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.