Unexpected intraoperative obstruction of frozen elephant trunk in patients who underwent total arch replacement

Abstract

Currently, total arch replacement (TAR) using frozen elephant trunk (FET) technique is gaining popularity for various thoracic aortic pathologies. FROZENIX is the first commercialized open stent-graft (OSG) in Japan, and it is a useful alternative to previously self-made OSG. FROZENIX is easy to deploy compared with formerly launched OSGs. However, some challenges have been identified with FROZENIX.Herein, we present the cases of two patients in whom we encountered serious unexpected kinking of FROZENIX during TAR performed using FET, which was related to its structural property. The clinical course and the bailout are described.

Kinking of Frozen Elephant Trunk Hybrid Prostheses: Incidence, Mechanism, and Management

“…Incidence of graft kinking with the Frozenix HP was more variable, and overall, the highest, which represents a great concern over the safety and effectiveness of this FET graft. Uchida et al ( 13 ) reported 2 cases of TAR with FET using the Frozenix J Open Graft, both of whom developed stent graft kinking which was related to the stent graft's structural property ( 13 ). Here, during the first case, specifically, after the Frozenix HP was inserted into the downstream aorta and its distal anastomosis completed, high cardiopulmonary bypass (CPB) flow-line pressure (300 mm Hg) and low femoral arterial pressure were noted, suggesting FET graft obstruction.…”

“…Other reported cases of kinking identified intraoperatively were treated by pulling out of the non-stent part of the graft proximally and then re-anastomosing the distal part into a distal site. Uchida et al ( 13 ) described performing this technique on a patient in Japan where the Frozenix stent graft was initially used. Similarly, for another patient, the same authors described taking out the Frozenix graft, trimming it, and re-anastomosing the graft more distally ( 13 ).…”

“…Uchida et al ( 13 ) described performing this technique on a patient in Japan where the Frozenix stent graft was initially used. Similarly, for another patient, the same authors described taking out the Frozenix graft, trimming it, and re-anastomosing the graft more distally ( 13 ).…”

“…The presentation of FET stent graft kinking is variable, and while it may be simply detected on follow-up imaging after FET with CT angiography (CTA), in many cases it may be distinguished by low arterial pressure in the lower limbs relative to upper limbs ( 13 ). Other case reports have stated that kinking may also manifest as intermittent claudication ( 14 ).…”

“…Other case reports have stated that kinking may also manifest as intermittent claudication ( 14 ). Additionally, studies have mentioned that the diagnosis of endostent graft kinking can occur both intra- and post-operatively ( 13 – 15 ).…”