The Stent Is Not to Blame: Lessons Learned With a Simplified US Version of the Frozen Elephant Trunk

Preventza, Ourania; Coselli, Joseph S.; Mayor, Jessica; Simpson, Keith; Carillo, Julius; Price, Matt D.; Cornwell, Lorraine D.; Omer, Shuab; Cruz, Kim I. de la; Bakaeen, Faisal G.; Jobe, Arin

doi:10.1016/j.athoracsur.2017.03.072

Cited by 20 publications

(14 citation statements)

References 31 publications

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“…Spinal cord coverage T8 or beyond (or stent length 15 cm) and spinal cord ischemia. We compared studies performed only in patients with spinal cord coverage T8 or beyond or 15 cm or greater stent length (n ¼ 6, 201 patients), 15,23,[32][33][34]42 with studies performed only in patients with stent length equal to 10 cm (n ¼ 19, 1634 patients). 15,[17][18][19]21,22,24,25,27,28,33,35,37,[40][41][42]45,46 The patients Figure E1).…”

Section: Subgroup Analysismentioning

confidence: 99%

“…When we compared studies performed only in patients with acute type A aortic dissection (n ¼ 12, 1300 patients) 21,23,25,[27][28][29][30]35,37,41,46,47 with studies performed only in patients with nonacute type A dissection and aneurysm (n ¼ 14, 741 patients), 14,15,17,19,22,[24][25][26]34,40,[42][43][44][45] we found the following results: The pooled mortality rate was 9.2% (95% CI, 6.9-12.4) in the patients with acute type A and 7.6% (95% CI, 4.9-11.4) in the patients with nonacute dissection and aneurysm (P ¼ .46). The pooled rate of stroke in these 2 groups was 9.3% (95% CI, 4.5-18.5) and 6.6% (95% CI, 3.1-13.5) (P ¼ .51), and the pooled rate of SCI was 2.4% (95% CI, 1.3-4.2) and 5.2% (95% CI, 3.1-8.5) (P ¼ .05), respectively ( Figure E2).…”

Section: Acute Type a Versus Nonacute Type A And Aneurysmmentioning

confidence: 99%

“…The summary pooled event rate is represented by the middle of the solid green diamond with the width of the diamond representing the 95% CI and indicates that 11.6% (95% CI, 6.1-21.1) of the patients with stent length 15 cm or greater or coverage T8 or beyond had a spinal cord ischemic event after FET, compared with 2.5% (95% CI, 1.5-4.0) of the patients with stent length 10 cm (P <.001). Note: For reference 42(Preventza 2017), the authors provided additional information not included in the publication. Among the 37 patients, the stent lengths used were 10 cm (n ¼ 14), 12.5 cm (n ¼ 1), and 15 cm (n ¼ 22).…”

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confidence: 99%

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Neurologic complications after the frozen elephant trunk procedure: A meta-analysis of more than 3000 patients

Preventza

Liao

Olive

et al. 2020

The Journal of Thoracic and Cardiovascular Surgery

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Objective: The frozen elephant trunk technique's safety regarding spinal cord ischemia has been questioned. We used a meta-analysis to determine the rates of adverse neurologic events and mortality. Methods:We searched PubMed/Medline, Embase, Scopus, and Cochrane databases (inception to April 2018) to identify studies of neurologic events after the frozen elephant trunk procedure. Separate meta-analyses were conducted with random-effects models to assess frozen elephant trunk associations with spinal cord ischemia, stroke, operative mortality, and all adverse events combined. Subgroup analyses compared outcomes in patients with acute versus nonacute type A dissection and aneurysm and with different extents of coverage.Results: Thirty-five studies (total N ¼ 3154) met inclusion criteria. The pooled rates of the outcomes of interest were 4.7% (95% confidence interval, 3.5-6.2) for spinal cord ischemia, 7.6% (95% confidence interval, 5.0-11.5) for stroke, and 8.8% (95% confidence interval, 7.0-10.9) for operative mortality. The spinal cord ischemia event rate was higher with stent length 15 cm or greater or coverage to T8 or beyond than with stent length of 10 cm (11.6% vs 2.5%, P<.001). Adverse event rates in patients with acute type A aortic dissection versus nonacute dissection or aneurysm were as follows: mortality 9.2% versus 7.6% (P ¼ .46), stroke 9.3% versus 6.6% (P ¼ .51), and overall adverse events 22.0% versus 16.5% (P ¼ .41). Conclusions:As the frozen elephant trunk procedure becomes more popular, accurate data regarding outcomes are vital. We associated the frozen elephant trunk technique with (nonsignificantly) more adverse events overall in acute type A dissection cases. Stent length of 10 cm was associated with significantly less risk of spinal cord ischemia. Using a stent 15 cm or greater or coverage extending to T8 or farther should be avoided. (J Thorac Cardiovasc Surg 2020;160:20-33) 35 Studies 3154 Patients 4.7% SCI 7.6% Stroke 8.8% Mortality Extent of SC Coverage Dissection (Type A or DeBakey Type I) / Aneurysm, Nondissection Overall Adverse Event (Mortality / Stroke / SCI) ≥ 15 cm stent length / Coverage at or distal to T8 (6 studies / 201 patients)From the

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Section: Subgroup Analysismentioning

confidence: 99%

Section: Acute Type a Versus Nonacute Type A And Aneurysmmentioning

confidence: 99%

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confidence: 99%

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Neurologic complications after the frozen elephant trunk procedure: A meta-analysis of more than 3000 patients

Preventza

Liao

Olive

et al. 2020

The Journal of Thoracic and Cardiovascular Surgery

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181

136

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“…Bilateral ACP is easily administered via a 9F Pruitt balloon-tip catheter inserted into the branches of the Y graft or, in cases of island arch repair, directly into the LCCA (LeMaitre Vascular, Burlington, Massachusetts, USA). The hybrid type III approach (12) is an open total arch operation used to treat the entire "mega-aorta" in one or two stages; the endovascular repair is performed on the descending thoracic aorta, and the "stented" landing zone facilitates the subsequent endovascular operations in the second stage (13,14). Type III arch repair, although it is described as "hybrid arch repair", should not be included and mixed with the hybrid techniques involving zone 0, because the patients and the stented area are different.…”

Section: Open Total Arch Replacementmentioning

confidence: 99%

Zone zero hybrid arch exclusion versus open total arch replacement

Preventza¹,

Tan

Orozco-Sevilla

et al. 2018

Ann. Cardiothorac. Surg.

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Open total aortic arch replacement is one of the most technically demanding operations in cardiothoracic surgery, requiring operator expertise and intraoperative and postoperative teamwork. Despite current advancements in the field of open aortic surgery with regard to intraoperative brain protection and postoperative care, the morbidity and mortality associated with open total arch operations varies. Endovascular and hybrid procedures involving the use of zone 0 as a landing zone allow fair comparison between open total arch and hybrid operations. Hybrid procedures involving all of the other landing zones [1-4] should not be compared with open total arch replacement, as the extent of the pathology is different.

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“…Of 64 studies reporting outcomes of patients included in this report 13–76 . The proportions of studies from Asia, Europe, and North America were 54.7%, 31.3%, and 10.9%, respectively.…”

Section: Methodsmentioning

confidence: 99%

Frozen elephant trunk in total arch replacement: A systematic review and meta‐analysis of outcomes and aortic proximalization

et al. 2021

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Background and Aim of the Study The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well as the predictors of outcomes are poorly identified. This systematic review and meta‐analysis explore FET outcomes and its predictors with a focus on zone aortic proximalization. Methods We searched PubMed/MEDLINE, EMBASE, and Scopus databases from their beginning to June 2020 to find studies reporting the outcomes of the FET procedure for the total arch replacement (TAR). Results A total of 64 studies including 7967 patients were evaluated. The pooled estimates of cerebrovascular accidents, paraplegia, renal failure, and in‐hospital mortality were 7.104 (95% confidence interval [CI], 5.691–8.661; I2 = 78.53%), 3.465 (95% CI, 2.852–4.136; I2 = 15.96), 14.969 (95% CI, 11.361–18.977; I2 = 91.26%), and 8.933 (95% CI, 7.128–10.919; I2 = 78.51%), respectively. Stratification by the geographical locations and by the aortic pathologies led to lower heterogeneity, but not for renal failure. The distal anastomosis in Zone 2 was associated with a lower rate of renal failure compared with Zone 3 (odds ratio, 0.54; 95% CI, 0.36–0.81; p = .003; I2 = 0%). Conclusions The FET procedure for TAR can be performed with acceptable mortality and morbidities among patients with complex aortic pathologies. Moreover, the distal anastomosis in Zone 2 was associated with lower renal failure compared to Zone 3.

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The Stent Is Not to Blame: Lessons Learned With a Simplified US Version of the Frozen Elephant Trunk

Cited by 20 publications

References 31 publications

Neurologic complications after the frozen elephant trunk procedure: A meta-analysis of more than 3000 patients

Neurologic complications after the frozen elephant trunk procedure: A meta-analysis of more than 3000 patients

Zone zero hybrid arch exclusion versus open total arch replacement

Frozen elephant trunk in total arch replacement: A systematic review and meta‐analysis of outcomes and aortic proximalization

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