Midterm Outcome after Frozen Elephant Trunk Procedures

Objectives: Frozen elephant trunk (FET) technique is used for the treatment of extensive thoracic aortic pathologies. The aim of this study was to analyze the midterm outcome after aortic arch replacement using FET technique, focusing on midterm survival and secondary procedures.

Methods: From October 2010 to August 2019, 118 patients (mean age 61.8 ± 14.2, 57.1% males) underwent aortic arch replacement using FET for aortic dissection (n = 34 acute; n = 39 chronic) or thoracic aneurysm (n = 45). Arch replacement was performed in zone 2 (n = 54) and zone 3 (n = 64). Concomitant procedures included aortic valve replacement (n = 10), aortic root replacement (n = 30), CAB (n = 9), mitral valve reconstruction (n = 1), and tricuspid valve reconstruction (n = 2). Follow-up was undertaken at our outpatient clinic at 3 months, and/or at 12 and 24 months postoperatively, depending on the findings of the initial evaluation at 3 months.

Results: Overall 30-day survival was 88.9%. Morbidity included cerebrovascular events (n = 14, 11.9%), spinal cord injury (n = 4, 3.4%), recurrent nerve palsy (n = 14, 11.9%), and acute renal failure (n = 25, 21.2%). Mean follow-up was 19.1 months (range: 0–98.9 months). Twenty-two of the 118 patients (18.6%) died within the first year. A further six patients died over a period of 4 years, after the first postoperative year. Causes of late mortality after 1 year included cancer (n = 2), heart failure (n = 1), vascular prosthetic graft infection (n = 1), unknown (n = 1), and multiorgan failure (n = 1).

Freedom from reintervention for the entire cohort at 3 months, and at 1, 3, and 5 years postoperatively was 90.7, 53.4, 36.6, and 31.3%, respectively. Forty-seven patients (39.8%) required one or more reinterventions: Crawford’s operation (n = 3), TEVAR (n = 36), fenestration (n = 2), EVAR (n = 9), open abdominal aortic repair (n = 4), and peripheral vascular stentgraft treatment (n = 4). Midterm reintervention rate for acute aortic dissections is 20.6%, as compared to a reintervention rate of 47.7% for chronic aortic dissections and thoracic aortic aneurysms.

Conclusion: The FET technique is associated with favorable midterm results. The high-post-FET reintervention rate for chronic aortic dissection and thoracic aneurysms can be attributed to the already existing pathology of the descending aorta. Postoperative follow-up at regularly intervals is mandatory to ensure timely and ö reintervention, should this be indicated by the findings.