Total arch replacement using frozen elephant trunk technique with Frozenix for distal aortic arch aneurysms

Open in a separate window OBJECTIVESTotal arch replacement (TAR) using an endovascular approach has been initially introduced as the frozen elephant trunk technique (FET). In our institute, TAR using the FET with Frozenix has been used as the first-line treatment for distal aortic arch aneurysms since 2014. This study aimed to evaluate the early and long-term outcomes and demonstrate the efficacy of this procedure.METHODSBetween 2014 and 2021, 121 consecutive patients were treated with TAR using the FET with Frozenix for distal aortic arch aneurysms. Early and long-term outcomes were retrospectively analysed.RESULTSThe 30-day mortality rate was 2.5% (3/121). Of postoperative complications, paraplegia due to spinal cord injury occurred in 2 (1.7%) patients, stroke in 12 (9.9%) and acute renal failure in 10 (8.3%). At follow-up, 23 secondary aortic interventions were required and 8 (6.6%) patients underwent intended secondary thoracic endovascular aortic repair for residual descending aortic aneurysm. Late and aortic-related deaths occurred in 16 (13.2%) and 4 (3.3%) patients, respectively. The overall long-term survival rates at 1, 3 and 5 years were 87.6%, 83.1% and 65.4%, respectively, while the rates of freedom from aortic-related death at 1, 3 and 5 years were 95.7%, 95.7% and 84.8%, respectively.CONCLUSIONSTAR using the FET with Frozenix for distal aortic arch aneurysms has acceptable early mortality and morbidity. Spinal cord injury and paraplegia occur less frequently than previously reported. The technique has satisfactory long-term survival and freedom from aortic-related death.     

Thoraflex hybrid as frozen elephant trunk in chronic,residual type A and chronic type B aortic dissection

OBJECTIVESThe frozen elephant trunk technique is an increasingly common treatment for extensive disease of the thoracic aorta. The objective of the study was to evaluate the outcomes of frozen elephant trunk specifically in chronic (residual) aortic dissections, focusing on downstream aortic remodelling.Open in a separate windowMETHODSBetween 2013 and 2019, a total of 28 patients were treated using the Vascutek Thoraflex hybrid graft at our institution for chronic dissections/post-dissection aneurysms. Immediate and follow-up outcomes were studied, as well as the changes in total aortic diameter, true lumen and false lumen diameter and the status of the false lumen at 3 different levels of the thoraco-abdominal aorta.RESULTSNo in-hospital or 30-day mortality was observed, temporary paraparesis rate was 7% and disabling stroke incidence was 14.3%. Freedom from all-cause mortality at 2 years was 91.6 ± 5.7%, while freedom from reintervention on the downstream aorta at 2 years was 59.1 ± 10.8%. Positive aortic remodelling was achieved in 50.0%, with an enlargement in the true lumen and a reduction of the false lumen not only at the level of the proximal descending aorta with 73.1% of complete thrombosis but also at the level of the distal descending thoracic aorta, with 41.7% of complete thrombosis.CONCLUSIONSThe frozen elephant trunk is a good solution in chronic (residual) downstream aortic dissections inducing positive aortic remodelling and preventing from II stage operations or allowing an endovascular approach.     

Left subclavian artery management in frozen elephant trunk: A novel technique

Proximilization of frozen elephant trunk (FET) necessitates the ligation and reimplantation of the left subclavian artery (LSA), the origin of which is distal and posterior, make rerouting difficult and cumbersome. We describe a rather simple technique for subclavian artery exposure and effective anatomical reconstruction in the mediastinum coupled with hybrid FET utilization for aortic aneurysm in elective and nonelective settings. The division of the sternocleidomastoid coupled with the sandbag behind the left shoulder brings the LSA superficial enabling anastomosis without any difficulty.     

Risk factors for stroke after total aortic arch replacement using the frozen elephant trunk technique

Open in a separate window OBJECTIVESThis study aimed to analyse risk factors for postoperative stroke, evaluate the underlying mechanisms and report on outcomes of patients suffering a postoperative stroke after total aortic arch replacement using the frozen elephant trunk technique.METHODSTwo-hundred and fifty patients underwent total aortic arch replacement via the frozen elephant trunk technique between March 2013 and November 2020 for acute and chronic aortic pathologies. Postoperative strokes were evaluated interdisciplinarily by a cardiac surgeon, neurologist and radiologist, and subclassified to each’s cerebral territory. We conducted a logistic regression analysis to identify any predictors for postoperative stroke.RESULTSOverall in-hospital was mortality 10% (25 patients, 11 with a stroke). A symptomatic postoperative stroke occurred in 42 (16.8%) of our cohort. Eight thereof were non-disabling (3.3%), whereas 34 (13.6%) were disabling strokes. The most frequently affected region was the arteria cerebri media. Embolism was the primary underlying mechanism (n = 31; 73.8%). Mortality in patients with postoperative stroke was 26.2%. Logistic regression analysis revealed age over 75 (odds ratio = 3.25; 95% confidence interval 1.20–8.82; P = 0.021), a bovine arch (odds ratio = 4.96; 95% confidence interval 1.28–19.28; P = 0.021) and an acute preoperative neurological deficit (odds ratio = 19.82; 95% confidence interval 1.09–360.84; P = 0.044) as predictors for postoperative stroke.CONCLUSIONSStroke after total aortic arch replacement using the frozen elephant trunk technique remains problematic, and most lesions are of embolic origin. Refined organ protection strategies, and sophisticated monitoring are mandatory to reduce the incidence of postoperative stroke, particularly in older patients presenting an acute preoperative neurological deficit or bovine arch.     

Aortic remodelling effect of the frozen elephant trunk technique on Stanford type A acute aortic dissection

Total arch replacement using the frozen elephant trunk procedure is performed for true lumen expansion of the descending aorta in patients with type A acute aortic dissection. However, the remodelling effect of the frozen elephant trunk on the dissected descending aorta is unclear. We aimed to evaluate the effect of the frozen elephant trunk on postoperative descending aortic remodelling after surgery. Between December 2012 and January 2020, we retrospectively investigated 24 patients who underwent total arch replacement using the frozen elephant trunk for type A acute aortic dissection. Remodelling of the descending aorta was evaluated using computed tomography. The aortic remodelling effect, based on aortic true lumen ratio, was determined for (i) DeBakey type (type I versus type III retrograde); (ii) thoracic endovascular aneurysm repair reintervention status (reintervention versus no reintervention); and (iii) stent length of the frozen elephant trunk (60 vs 90 mm). Postoperative true lumen ratio significantly increased in the type I dissection group. The true lumen ratio in the no-reintervention group, which had many patients with the type I dissection, significantly increased after the frozen elephant trunk. Aortic remodelling due to the frozen elephant trunk can be expected after type I acute aortic dissections.     

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

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.     

孙氏手术治疗急性Stanford A型主动脉夹层

目的 总结急性Stanford A型主动脉夹层采用孙氏手术(主动脉弓部替换加支架象鼻手术)的临床经验与随访结果.方法 2004年8月至2012年3月,73例急性A型夹层患者施行了孙氏手术,其中男60例、女13例,平均年龄49.6(26 ～79)岁.手术均采用深低温停循环、低流量选择性脑灌注技术.单纯行升主动脉替换加孙氏手术30例;主动脉根部替换(Bentall术)加孙氏手术10例,主动脉瓣及升主动脉替换加孙氏手术12例,主动脉瓣成形加孙氏手术21例(同时行主动脉窦重建16例),同期行冠状动脉旁路移植术( CABG)9例,术后通过CTA评价胸腹主动脉塑形及假腔愈合情况.结果 体外循环平均(248.1±69.8)min,选择性脑灌注(38.2±10.5)min.手术死亡5例(6.85％,5/73例).术后60例随访2个月～7.6年,术后3个月CTA复查显示,91.7％的患者主动脉夹层的假腔在膈肌水平形成血栓,患者术后1、5和7年的生存率分别是97％、87％和81％.结论 孙氏手术治疗急性A型主动脉夹层安全有效且远期效果令人满意.     

杂交技术治疗DeBakeyⅠ型夹层的早中期结果

目的:比较杂交和冷冻象鼻(FET)技术治疗DeBakeyⅠ型主动脉夹层的早中期结果。方法:回顾性分析2010年1月~2016年12月阜外医院血管外科中心诊治的937例DeBakeyⅠ型主动脉夹层患者的临床资料。815例(86.9%)患者行常规全弓替换+FET植入术(FET组);122例(13.1%)患者行头臂血管去分支+同期全弓腔内介入支架修复术(杂交组)。通过匹配分析方法确定了109对患者进行均衡比较。结果:(1)全组患者分析结果:全组平均年龄48.6岁,杂交组高于FET组(61.3岁比46.7岁,P<0.001)。全组早期死亡98例(10.5%,98/937),杂交组11例(9%,11/122),FET组87例(10.7%,87/815)(P=0.577);全组复合并发症率19.6%(184/937),杂交组[15.6%(19/122)]和FET组[20.2%(165/815)]比较差异无统计学意义(P=0.226);杂交组术后无持续性神经功能障碍发生,FET组有72例(8.8%)(P=0.010)。(2)匹配组分析结果:杂交组死亡率及复合并发症率均低于FET组,但两组比较差异无统计学意义[9.2%(10/109)比17.4%(19/109),P=0.073;15.6%(17/109)比25.7%(28/109),P=0.066]。术后新发肾功能不全、肝功能不全以及截瘫发生率,杂交组均低于FET组(P=0.013,P=0.022及P=0.014)。胸段假腔完全血栓化率杂交组均高于FET组[支架段:87.8%(79/90)比75.3%(58/77),P=0.044;下胸段:43.3%(39/90)比27.3%(21/77),P=0.038]。杂交组3、5及7年生存率分别为95.7%、91.7%及91.7%,FET组分别为95.6%、93.7%及82%(P=0.320)。结论:杂交全弓技术治疗DeBakeyⅠ型主动脉夹层有改善术后早期死亡和复合并发症的趋势;相比FET技术,杂交技术显著降低术后脊髓损伤和肝肾功能不全发生率,更能促进中远期胸段夹层假腔的完全血栓化。     

Downstream thoracic endovascular aortic repair following zone 2, 100-mm stent graft frozen elephant trunk implantation

Open in a separate window OBJECTIVESThe aim of this study was to analyse outcomes of downstream thoracic endovascular aortic repair (TEVAR) following the frozen elephant trunk (FET) procedure.METHODSSixty-six patients underwent downstream TEVAR following the FET procedure to treat thoracic aortic dissections (n = 42, 64%), aneurysms (n = 19, 29%) or penetrating aortic ulcers involving the aortic arch (n = 5, 8%). Patient and outcome characteristics were analysed.RESULTSDownstream TEVAR was performed 7 [interquartile range: 2–18] months after the FET procedure in 39 male (59%) and 27 female (41%) patients aged 68 [interquartile range: 56, 75] years, including 11 patients (17%) with a connective tissue disease. Before TEVAR, cerebrospinal fluid drainage was put in place in 61 patients (92%). Patients were treated with 1 stent graft (n = 28, 42%), 2 stent grafts (n = 37, 56%) or 3 stent grafts (n = 1, 2%). The femoral artery was accessed through surgical cut-down (n = 15, 23%) or percutaneously (n = 49, 74%). One patient (2%) developed a temporary spinal cord injury that resolved spontaneously. No case of permanent spinal cord injury, stroke or death was observed. After 12 [interquartile range: 2–23] months, 15 patients required an additional aortic reintervention (endovascular: n = 6; surgical: n = 9).CONCLUSIONSDownstream TEVAR following the FET procedure is associated with excellent clinical outcomes. We thus maintain that staging thoracic aortic repair—FET and secondary TEVAR—is a very successful and safe strategy. Certain patients might need a tertiary procedure to fix their entire aortic pathology; therefore, they will require long-term continuous follow-up, ideally in a dedicated aortic clinic.     

Outcome of the frozen elephant trunk procedure as a redo operation

 Open in a separate windowOBJECTIVESThe goal of this study was to determine the outcome of patients undergoing an elective frozen elephant trunk (FET) procedure as a redo operation following previous cardiac surgery.METHODSOne hundred and eighteen consecutive patients underwent FET procedures between October 2010 and October 2019 at our centre. Patients were registered in a dedicated database and analysed retrospectively. Clinical and follow-up characteristics were compared between patients undergoing a FET operation as a primary (primary group) or a redo procedure (redo group) using logistic regression and Cox regression analysis. Emergency procedures (n = 33) were excluded from the analysis.RESULTSA total of 36.5% (n = 31) of the FET procedures were redo operations (redo group) and 63.5% (n = 54) of the patients underwent primary surgery (primary group). There was no significant difference in the 30-day mortality [primary group: 7.4%; redo group: 3.2%; 95% confidence interval (CI) (0.19–35.29); P = 0.63] and the 3-year mortality [primary group: 22.2%; redo group: 16.7%; 95% CI (0.23–3.23); P = 0.72] between redo and primary cases. Furthermore, the adjusted statistical analysis did not reveal significant differences between the groups in the occurrence of transient or permanent neurological deficit, paraplegia, acute renal failure and resternotomy. The redo group showed a higher rate of recurrent nerve palsy, which did not reach statistical significance [primary group: 3.7% (n = 2); redo group: 19.4% (n = 6); P = 0.091].CONCLUSIONSElective FET procedures as redo operations performed by a dedicated aortic team following previous cardiac surgery demonstrate an adequate safety profile.     

深低温停循环下升主动脉全弓置换联合降主动脉远端支架“象鼻”植入术的护理配合

目的提供深低温停循环下升主动脉全弓置换联合降主动脉远端支架"象鼻"植术的护理配合程序和护理经验。方法选择我院2013年5月至2016年12月收治Stanford A型主动脉夹层患者38例,均成功实施深低温停循环下升主动脉全弓置换联合降主动脉远端支架象鼻手术,对其手术的护理配合进行总结分析。结果全组38例患者均手术成功,出院后随访2~27个月,患者生存良好。结论加强Stanford A型主动脉夹层的手术配合有利于减少手术风险。     

Frozen elephant trunk technique and partial remodeling for acute type A aortic dissection

Objective: The aimed to describe the frozen elephant trunk (FET) technique and partial remodeling (PR) for acute type A aortic dissection (ATAAD), considering the long-term prognosis on the basis of our 13 years of experience. Methods: There were 80 consecutive patients (mean age: 66.4 years) with an FET and PR technique for ATAAD between September 1997 and February 2010. We indicated a PR for all 80 patients without dilatation of the sinuses and a FET for 20 patients with a distal entry in the descending aorta, 14 patients with a dilatation more than 4 cm on the distal arch and 46 patients with a narrow true lumen younger than 70 years with a narrow true lumen. During moderate hypothermic circulation with selective cerebral perfusion and distal perfusion from the femoral artery, a stent graft (mean diameter: 27.7 mm, mean length: 9.9 mm, mean distal depth: thoracic vertebra (Th) 6.0th) was inserted through the transected proximal aortic arch. The plication of the sinotubular junction (N = 42) or partial remodeling for right and/or non-coronary cusp (N = 38) was performed after total arch replacement with a four-branched prosthesis. Results: Four patients died in hospital. Early morbidity included two (2.5%) strokes but no spinal cord injury. In long-term follow-up (mean 94.6 months), five patients died of non-aortic events and two re-operations (Bentall and stent grafting to the descending aorta) were required. No patients had patent false lumen on the stent graft and residual aortic regurgitation, according to late follow-up computed tomography (CT) and echogram. The 10-year survival was 75% and the overall 10-year re-operation free rate on the thoracic aorta was 95%. Conclusion: FET and modified PR techniques could be effective for improving the long-term outcome on the distal and proximal aorta in an ATAAD.     

Outcomes of reoperation for total arch replacement combined with frozen elephant trunk after previous cardiovascular surgery

BackgroundAortic arch replacement(TAR) combined with frozen elephant trunk (FET) technique is a high-risk operation after previous cardiovascular surgery. The aim of the study was to review our strategy and outcomes in this cohort.MethodData were reviewed for patients who underwent TAR combined with FET after previous cardiovascular surgery from January 2010 to December 2020. The patients were divided into elective group and non-selective group.Results63 eligible patients were divided into elective(n = 44) and non-elective(n = 19) groups. The interval between two operations was shorter in non-elective group than elective groups (P = 0.001). The indication for reoperation was different in two groups (P = 0.000), however, the type of reoperations has no differences. Cardiopulmonary bypass time was shorter in elective group than non-elective group (P = 0.000). The over-all 30-day mortality rate was 17.5%, and it was higher in non-elective group (P = 0.013). The 24h drainage increased in non-elective group (P = 0.001) as well as re-explore rate for bleeding (P = 0.022). Postoperative hospital stay prolonged in non-elective group (P = 0.002). However, rates of survival without further aortic events were 72.3 ± 7.1% in elective group, 72.9 ± 13.5% in non-elective group at 5 years, respectively (P = 0. 955).ConclusionReduced 30-day mortality and shortened post-operative hospital stay was observed in elective group, however, long-term survival rate without reintervention were not affected.     

Frozen elephant trunk in acute type A aortic dissection: surgical techniques and the extracorporeal circuit management

Acute type A aortic dissection (ATAAD) is a challenging clinical condition with immediate and late complications. Frozen elephant trunk (FET) has been offered as a solution for it promises to address the late complications—false lumen thrombosis and aortic remodelling. Here, we describe the implantation of the FET in ATAAD with the surgical technique and extracorporeal circuit management. A 54-year-old male presented with retrograde type A aortic dissection with an entry point distal to the left subclavian artery. He underwent FET using Thoraflex™ hybrid vascular prosthesis (Vascutek, Inchinnan, Scotland). Three-month follow-up showed a complete obliteration of the false lumen in the descending thoracic aorta. FET in ATAAD is a valid option in the hands of experienced surgeons, while patient selection still remains the key in this surgery.     

Staged repair of a thoracoabdominal aortic aneurysm with mesenteric ischemia using the reversed elephant trunk technique

Improvements in surgical techniques, and adjuncts for spinal cord protection and perioperative care have resulted in decreased morbidity and mortality in repair of thoracoabdominal aortic aneurysm (TAAA). However the surgical treatment of TAAA of extent II is still associated with high mortality, especially in patients with preoperative co-morbidities. We report a successful staged repair of extent II TAAA using the reversed elephant trunk technique for a patient with ischemic colitis. (Jpn J Thorac Cardiovasc Surg 2006; 54:203-206)     

Covered frozen elephant trunk technique for prevention of distal stent graft-induced new entry

Distal stent graft-induced new entry is not rare after frozen elephant trunk implantation. We report a case of covered frozen elephant trunk placement for prevention of distal stent graft-induced new entry. Coverage of the rigid distal stent edge using a graft reduces mechanical stress on the intima and radial force of the distal stent; therefore, this technique can potentially prevent distal stent graft-induced new entry.     

Progress of the treatment for extended aortic aneurysms; is the frozen elephant trunk technique the next standard in the treatment of complex aortic disease including the arch?

Patients with extensive aortic aneurysms involving the ascending aorta, aortic arch, and the descending aorta are still considered to be a challenge for many cardiovascular surgeons. The introduction of the elephant trunk technique by Borst et al. in 1983 has greatly facilitated surgery on this kind of pathology and this technique has been recognized as a standard modality for treatment of extended aortic aneurysms. As a next step, the frozen elephant trunk technique has been introduced in some institutes in the late 1990s. With this technique, surgery is performed through a median sternotomy, and an endovascular stent-graft is placed into the descending aorta in an antegrade fashion through the opened aortic arch. Then the ascending aorta and the aortic arch are replaced conventionally. The frozen elephant trunk technique enables one-stage repair of extended aortic aneurysms in a certain patient cohort with similar operative mortality as with the conventional elephant trunk technique, in which a second-stage operation is a prerequisite. Although the surgical strategy should be adjusted specifically to each patient's individual pathology, the frozen elephant trunk technique may become the next standard treatment for extended aortic aneurysm instead of its conventional variant.