Post-implantation syndrome after frozen elephant trunk is associated with the volume of new-onset aortic thrombus

Abstract

Background: Post-implantation syndrome (PIS) is defined as non-infectious continuous fever and a concomitant rise in inflammatory markers shortly after endovascular aortic repair. PIS occurrence after hybrid procedures, such as the frozen elephant trunk (FET) technique, has not been adequately investigated. The current study aims to define the incidence of PIS after the FET and to identify possible risk factors associated with its occurrence. Methods: The clinical charts of 59 patients undergoing the FET between February 2015 and April 2020 were reviewed retrospectively. The occurrence of PIS was defined as the presence of fever (>38 ℃ lasting longer than one day during the hospitalisation) and leucocytosis (white blood cell count >12,000/µL).Patients with concomitant conditions possibly leading to fever and/or leucocytosis were excluded. Beside demographic and procedure-related data, serum/plasma inflammatory markers were evaluated before surgery and daily up to seven days postoperatively. Computed tomography scans (CT) were examined to calculate the volume of pre-existent and new-onset mural thrombus after the FET. Results: Thirty-eight patients met the inclusion criteria. The study cohort was divided into two groups based on the occurrence of PIS (17 cases; 44.7%). Patients with PIS were significantly younger than those without PIS (53.5±8.9 vs. 62.5±9.6 years; P=0.005). Female patients were less likely to develop PIS (5.2% vs. 26.3%, P=0.018). Patients with PIS had a higher volume of new-onset thrombus in the postoperative CT (P<0.001). Patients treated for post-dissection aneurysm had, postoperatively, significantly more thrombus material developed in a false lumen (P=0.02). Among the PIS markers, CRP (C-reactive protein) levels on the third postoperative day were independently associated with the volume of new-onset thrombus (P=0.011).After multivariate analysis, the volume of new-onset thrombus (P=0.028) and age (P=0.036) remained the variable associated with a statistically significant increased incidence of PIS.Conclusions: PIS can occur after the frozen elephant trunk procedure. The volume of new-onset thrombus seems to be associated with an increased incidence of PIS. These findings need to be confirmed in larger patient cohorts.

Unveiling the Enigma of Post-implantation Syndrome Following Aortic Dissection Repair: A Case Report

“…Several studies have investigated the incidence of PIS after aortic dissection repair surgery. In a retrospective study of 38 patients who underwent a frozen elephant trunk procedure, the incidence of PIS was 44.7% [ 7 ]. Another study of 74 patients who underwent thoracic endovascular aortic repair (TEVAR) reported an incidence of PIS of 22.97% [ 8 ].…”

“…The wide range of reported incidence rates can be attributed to differences in patient populations and surgical techniques used in these studies. Ibrahim et al mentioned in their study that PIS occurred in patients who underwent open frozen trunk procedures for type A dissection and ascending aortic aneurysms [ 7 ]. Volevski et al [ 8 ] have reported in their study that PIS occurred following TEVAR.…”

Impact of Frozen and Conventional Elephant Trunk on Aortic New-Onset Thrombus and Inflammatory Response

“…In the literature, its incidence varies widely. In the setting of type B aortic dissections treated with thoracic endovascular aortic repair (TEVAR), PIS incidence has been previously described amounting to 15.8–31.6% [ 11 , 15 ]; in the context of FET, a previous study reported an incidence of 44.7% [ 6 ]. The pathophysiological mechanism of PIS is still largely unknown, while efforts have been made to collect evidence regarding its risk factors.…”

“…In the perioperative care of endovascular-treated patients, post-implantation syndrome is a well-known clinical entity. It was initially described, after endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) [ 5 ], as a systemic inflammatory response occurring in the early postoperative period and is defined as continuous fever and leukocytosis in the absence of an infection focus; its incidence has been reported amounting to circa 45% in the context of FET [ 6 ]. With the growing application of hybrid stent grafts such as FET for aortic arch lesions and for extensive thoracoabdominal aortic pathologies, PIS issues are becoming increasing relevant in postoperative care.…”

Fever Management after TEVAR in Patients with Aortic Dissection

“…The exact pathophysiology of PIS and its effects on long-term clinical outcomes remain unclear. Age, medical history, the composition of implanted stent grafts, and the new-onset aortic thrombus volume have been identified as risk factors promoting the occurrence of PIS [6,7,8,10,11,12,13,14,15,16,17,18,19,20,21]. Furthermore, its effect on patient outcomes is a concern because it may lead to prolonged hospitalisation and longer ICU stays [11,12,13,14].…”