Debranching-first followed by aortic arch replacement with frozen elephant trunk

Abstract

Background: Diffuse thoracic aortic aneurysm has been a challenge for cardiovascular surgeons as aortic arch and descending aortic aneurysm should be treated simultaneously somehow. The total arch replacement (TAR) using a frozen elephant trunk (FET) allows them to treat aortic arch and descending aortic pathology at once via median sternotomy. Besides, extra-anatomical bypass performed between the left common carotid artery (CCA) and subclavian artery (SCA) prior to TAR allowed further proximalization of FET prosthesis and facilitated distal anastomosis of TAR and spared the demanding Left subclavian artery (LSA) anastomosis in deep pericardial space. We investigated the efficacy of this debranching-first technique followed by total arch replacement using a frozen elephant trunk as a two-stage operation for extensive thoracic aortic aneurysm among high-risk patients. Methods: Forty-nine consecutive patients with diffuse degenerative aneurysms from the aortic arch to the descending aorta or chronic aortic dissection receiving left common carotid to subclavian artery bypass followed by total arch replacement using a frozen elephant trunk and possible subsequent thoracic endovascular aortic repair between 2016 and 2021 were analysed. The baseline characteristics and clinical outcomes were demonstrated. Overall survival rate and 5-year aortic event-free survival, aortic reintervention rates were analysed. Results: The average score of European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 4.7±2.5. The operative mortality rate was 4.1%, with no paraplegia events. The five-year overall survival, cumulative aortic related mortality were 76.8%, 2%, respectively. The five-year overall cumulative aortic reintervention rates including intended intervention were 31.3%. The 5-year cumulative rate of non-intended reintervention was 4.5%. Conclusions: The assessed technique enables a less invasive and less technically demanding surgery with reasonable outcomes. The 5-year aortic event-free survival and reintervention rates were acceptable, suggesting that multiple stages of alternative open and endovascular interventions, such as this technique, may reduce the morbidity and mortality rates of high-risk patients with diffuse thoracic aortic aneurysm. Clinical registration number: 2022001