Distal Aortic Failure Following the Frozen Elephant Trunk Procedure for Aortic Dissection

Abstract

BackgroundAim of this study was to report and to identify risk factors for distal aortic failure following aortic arch replacement via the frozen elephant trunk (FET) procedure.MethodsOne hundred eighty-six consecutive patients underwent the FET procedure for acute and chronic aortic dissection. Our cohort was divided into patients with and without distal aortic failure. Distal aortic failure was defined as: (I) distal aortic reintervention, (II) aortic diameter dilatation to ≥ 6 cm or > 5 mm growth within 6 months, (III) development of a distal stent-graft-induced new entry (dSINE) and/or (IV) aortic-related death. Preoperative, intraoperative, postoperative and aortic morphological data were analyzed.ResultsDistal aortic failure occurred in 88 (47.3%) patients. Forty-six (24.7%) required a distal reintervention, aortic diameter dilatation was observed in 9 (4.8%) patients, a dSINE occurred in 22 (11.8%) patients and 11 (6.4%) suffered an aortic-related death. We found no difference in the number of communications between true and false lumen (p = 0.25) but there were significantly more communications between Ishimaru zone 6–8 in the distal aortic failure group (p = 0.01). The volume of the thoracic descending aorta measured preoperatively and postoperatively within 36 months afterward was significantly larger in patients suffering distal aortic failure (p < 0.001; p = 0.011). Acute aortic dissection (SHR 2.111; p = 0.007), preoperative maximum descending aortic diameter (SHR 1.029; p = 0.018) and preoperative maximum aortic diameter at the level of the diaphragm (SHR 1.041; p = 0.012) were identified as risk factors for distal aortic failure.ConclusionThe incidence and risk of distal aortic failure following the FET procedure is high. Especially those patients with more acute and more extensive aortic dissections or larger preoperative descending aortic diameters carry a substantially higher risk of developing distal aortic failure. The prospective of the FET technique as a single-step treatment for aortic dissection seems low and follow-up in dedicated aortic centers is therefore paramount.

Aortic shape variation after frozen elephant trunk procedure predicts aortic events: Principal component analysis study

“…The mid- to long-term reports on incidence of aortic events after the FET vary in many studies ranging from approximately 16% to 47%. 5 , 21 , 22 , 23 , 24 This variability is mainly due to specifically selected patient cohorts under investigation and variable definitions of composite aortic events. Given the applicability of the FET procedure to many aortic pathologies, high incidence of distal aortic failure, and need for future aortic procedures, there is an urgent need for accurate predictors of aortic remodeling and adverse aortic events.…”

“…Given the applicability of the FET procedure to many aortic pathologies, high incidence of distal aortic failure, and need for future aortic procedures, there is an urgent need for accurate predictors of aortic remodeling and adverse aortic events. 22 , 23 , 24 Furthermore, the FET procedure and its modified versions are increasingly more favored surgical approaches in the treatment of thoracic aortic disease in a younger patient population with tissue hereditary diseases, which translates to a lifetime of exposure and increased long-term risk of aortic events. Current surveillance techniques describe aortic remodeling after the FET in terms of TL and FL size parameters or aortic growth rate.…”

Evidence-based frozen elephant trunk practice: a narrative review

“…The ‘spring back force’ is the force generated when the graft tries to straighten itself to its natural configuration, which acts upon the aortic wall, causing it to develop dSINE ( 30 ). On the contrary, Berger et al found that AAD is a significant risk factor for distal aortic failure after the FET procedure compared to CAD, likely due to vulnerability of the dissection membrane in the acute phase which increases the likelihood of developing dSINE ( 31 ). Furutachi et al noted that the Frozenix graft had a strong spring back force, whereas the THP design has been found to reduce the sheer stress on the intima which can explain its more favourable results in other studies ( 30 , 32 ).…”

Hybrid Treatment of Complex Diseases of the Aortic Arch and Descending Thoracic Aorta by Frozen Elephant Trunk Technique

“…In a recent meta-analysis over 37 studies including 4178 patients, overall survival at 1, 3, and 5 years was 89.6%, 85.2%, and 82.0%, respectively, with freedom from reintervention of 93.9%, 89.3%, and 86.8%, respectively [11]. Thus, close follow-up in dedicated aortic centers is mandatory to decrease the risk of aortic-related events and to plan when needed a second-stage procedure [8][9][10][11][12][13]34,36].…”