Simplified Frozen Elephant Trunk Technique for Combined Open and Endovascular Treatment for Extensive Aortic Diseases Leads to Better Early Outcomes

 

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Objectives: The frozen elephant trunk (FET) procedure is a treatment of patients with extensive thoracic aortic disease involving the arch and descending aorta. Despite modern cerebral perfusion strategies, early morbidity and mortality remain high due to the complex surgical technique. This study analyses the impact of a simplified FET technique on early outcome.

Methods: Between July 2011 and September 2016, a total of 67 consecutive patients (mean age, 65.1 ± 10.7 years) underwent FET surgery using the Vascutek Thoraflex (n = 56 patients) or the Jotec Evita open (n = 11 patients) hybrid prosthesis during moderate circulatory arrest and selective antegrade cerebral perfusion. Underlying pathologies were complex thoracic aneurysm in 24 (35.8%), acute aortic dissection in 24 (35.8%), and chronic dissection in 19 patients (28.4%). In 12 patients, a simplified FET technique with deployment and fixation of the stent graft in aortic arch zone 2 and overstenting of the left subclavia artery (LSA) was performed. Of these patients, 7 patients underwent additional carotid-LSA bypass (zone 2) and in 5 patients, the first branch of the Thoraflex prosthesis was anastomosed to the distal part of the LSA using a supraclavicular access during reperfusion and rewarming of the patient. In 55 patients, the stent graft was deployed in arch zone 3.

Results: Total operation (359.8 ± 55.2 vs. 437.5 ± 123.3 minutes; p = 0.046), cardiopulmonary bypass (207.7 ± 56.1 vs. 288.2 ± 87.3 minutes; p = 0.003), cross-clamp (105.3 ± 57.9 vs. 150.1 ± 64.6 minutes; p = 0.03), circulatory arrest (45.9 ± 12.3 vs. 77.8.9 ± 39.8 minutes; p = 0.008), and selective antegrade cerebral perfusion (61.7 ± 11.8 vs. 93.5 ± 39.5 minute; p = 0.008) times were significantly reduced in zone 2 versus zone 3 stent placement, respectively. 30-day mortality rate was 8.3% (1 patient) in zone 2 versus 16.4% in zone 3 group (p=ns.). The patient in zone 2 group died due to sepsis after an uneventful perioperative period, which was unrelated to the surgical technique. There were no permanent neurologic deficit (0 vs. 11 patients), spinal cord injury (0 vs. 2 patients), and recurrent nerve palsy in zone 2 compared with zone 3 (p < 0.001).

Conclusion: Although the FET technique remains a challenging surgical technique, the complexity of the procedure can significantly be reduced by stent graft deployment in aortic arch zone 2. Thus, simplifying the FET procedure leads to better early outcomes.