The aim of this study was to evaluate the midterm outcomes of secondary extension of frozen elephant trunk (FET) by means of thoracic endovascular aortic repair (TEVAR).
Methods:
This single-center prospective study was conducted in a tertiary aortic center on consecutive patients having undergone TEVAR with an endograft covering most of the 10 cm FET module with 2 to 4 mm oversizing. All patients were monitored by computerized tomography angiography (CTA) at sixth month and yearly thereafter.
Results:
From January 2015 to July 2022, among 159 patients who received FET, 30 patients (18.8%) underwent a TEVAR procedure (13 for a thoracoabdominal aneurysm, 11 for a chronic aortic dissection and 6 for an emergency procedure). All connections were successfully achieved with 2 postoperative deaths (6.6%) and 1 paraplegia (3.3%). At a median follow-up of 21 months (interquartile range [IQR], 4.2–34.7), 5 patients (25%) required a fenestrated-branched endovascular aortic repair (F-BEVAR) extension followed by 4 patients with 5 reinterventions, 3 for a Type 3 endoleak due to disconnection between FET and TEVAR endograft, and 2 unrelated to the FET for a secondary Type 1C endoleak. All reinterventions were successful, without mortality or morbidity.
Conclusions:
In this series, FET connection with a TEVAR endograft was effective with low postoperative morbidity but with a risk of aortic reintervention related to disconnection between the FET and TEVAR endograft. These results suggest the need for annual CTA monitoring with no time limit in patients following connection of the FET with a TEVAR endograft.
Clinical Impact
In this series of 30 patients, midterm outcomes of secondary extension of frozen elephant trunk (FET) by thoracic endovascular repair (TEVAR) showed 3 disconnections (10%) with a Type 3 endoleak between FET and TEVAR. These findings suggest the need for annual CTA monitoring with no time limit. But so far, only a few studies provide some information after one year while the risk of disconnection increases over time and becomes a concern after 3 years. This is the new message brought by our study.
KatoMOhnishiKKanekoM, et al. New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft. Circulation. 1996;94(9)(suppl):II188–II193.
2.
KarckMChavanAHaglC, et al. The frozen elephant trunk technique: a new treatment for thoracic aortic aneurysms. J Thorac Cardiovasc Surg. 2003;125(6):1550–1553. doi:10.1016/s0022-5223(03)00045-x.
3.
RustumSBeckmannEWilhelmiM, et al. Is the frozen elephant trunk procedure superior to the conventional elephant trunk procedure for completion of the second stage?Eur J Cardiothorac Surg. 2017;52(4):725–732. doi:10.1093/ejcts/ezx199.
4.
ArnaoutakisDJScaliSTBeckAW, et al. Comparative outcomes of open, hybrid, and fenestrated branched endovascular repair of extent II and III thoracoabdominal aortic aneurysms. J Vasc Surg. 2020;71(5):1503–1514. doi:10.1016/j.jvs.2019.08.236.
5.
PoldermansDBaxJJBoersmaE, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: the Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur J Anaesthesiol. 2010;27(2):92–137. doi:10.1097/EJA.0b013e328334c017.
6.
StaitiehBSIoachimescuOC.Interpretation of pulmonary function tests: beyond the basics. J Investig Med. 2017;65(2):301–310. doi:10.1136/jim-2016-000242.
7.
PorriniERuggenentiPLuis-LimaS, et al. Estimated GFR: time for a critical appraisal. Nat Rev Nephrol. 2019;15(3):177–190. doi:10.1038/s41581-018-0080-9.
8.
StellaAFreyrieAGargiuloM, et al. The advantages of anaconda endograft for AAA. J Cardiovasc Surg (Torino). 2009;50(2):145–152.
9.
CzernyMPaciniDAboyansV, et al. Current options and recommendations for the use of thoracic endovascular aortic repair in acute and chronic thoracic aortic disease: an expert consensus document of the European Society for Cardiology (ESC) Working Group of Cardiovascular Surgery, the ESC Working Group on Aorta and Peripheral Vascular Diseases, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg. 2021;59(1):65–73. doi:10.1093/ejcts/ezaa268.
10.
MelissanoGTshombaYBertoglioL, et al. Analysis of stroke after TEVAR involving the aortic arch. Eur J Vasc Endovasc Surg. 2012;43(3):269–275. doi:10.1016/j.ejvs.2011.12.009.
11.
BischoffMSScheumannJBrennerRM, et al. Staged approach prevents spinal cord injury in hybrid surgical-endovascular thoracoabdominal aortic aneurysm repair: an experimental model. Ann Thorac Surg. 2011;92(1):138–146; discussion 146. doi:10.1016/j.athoracsur.2011.03.098.
12.
de SouzaLROderichGSFarberMA, et al. Editor’s choice—comparison of renal outcomes in patients treated by Zenith((R)) fenestrated and Zenith((R)) abdominal aortic aneurysm stent grafts in US prospective pivotal trials. Eur J Vasc Endovasc Surg. 2017;53(5):648–655. doi:10.1016/j.ejvs.2017.02.005.
13.
MalloyPCRaghavanAElderT, et al. Cerebrospinal fluid drainage during endovascular aortic aneurysm repair: a systematic review of the literature and treatment recommendations. Vasc Endovascular Surg. 2020;54(3):205–213. doi:10.1177/1538574419896525.
14.
IsselbacherEM.Thoracic and abdominal aortic aneurysms. Circulation. 2005;111(6):816–828. doi:10.1161/01.CIR.0000154569.08857.7A.
15.
ErbelRAboyansVBoileauC, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC). Eur Heart J. 2014;35(41):2873–2926. doi:10.1093/eurheartj/ehu281.
16.
ShresthaMBeckmannEKruegerH, et al. The elephant trunk is freezing: the Hannover experience. J Thorac Cardiovasc Surg. 2015;149(5):1286–1293. doi:10.1016/j.jtcvs.2015.01.044.
17.
DakeMDThompsonMvan SambeekM, et al. DISSECT: a new mnemonic-based approach to the categorization of aortic dissection. Eur J Vasc Endovasc Surg. 2013;46(2):175–190. doi:10.1016/j.ejvs.2013.04.029.
18.
LopesAGouveia MeloRGomesML, et al. Aortic dissection repair using the STABILISE technique associated with arch procedures: report of two cases. EJVES Short Rep. 2019;42:26–30. doi:10.1016/j.ejvssr.2019.01.003.
19.
WatkinsACHuasenABHillA, et al. Endovascular aortic repair for early complications after implantation of the thoraflex hybrid graft. Ann Thorac Surg. 2019;107(3):e171–e174. doi:10.1016/j.athoracsur.2018.07.061.
20.
OderichGSForbesTLChaerR, et al. Reporting standards for endovascular aortic repair of aneurysms involving the renal-mesenteric arteries. J Vasc Surg. 2021;73(1S):4S–52S. doi:10.1016/j.jvs.2020.06.011.
21.
GrabenwogerMAlfonsoFBachetJ, et al. Thoracic endovascular aortic repair (TEVAR) for the treatment of aortic diseases: a position statement from the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2012;42(1):17–24. doi:10.1093/ejcts/ezs107.
22.
ThomasMEBlaineCDawnayA, et al. The definition of acute kidney injury and its use in practice. Kidney Int. 2015;87(1):62–73. doi:10.1038/ki.2014.328.
23.
ThygesenKAlpertJSWhiteHD, et al. Universal definition of myocardial infarction. Circulation. 2007;116(22):2634–2653. doi:10.1161/CIRCULATIONAHA.107.187397.
24.
MaynardFMJrBrackenMBCreaseyG, et al. International standards for neurological and functional classification of spinal cord injury. American Spinal Injury Association. Spinal Cord. 1997;35(5):266–274. doi:10.1038/sj.sc.3100432.
25.
KwahLKDiongJ.National Institutes of Health Stroke Scale (NIHSS). J Physiother. 2014;60(1):61. doi:10.1016/j.jphys.2013.12.012.
26.
KreibichMBergerTMorlockJ, et al. The frozen elephant trunk technique for the treatment of acute complicated Type B aortic dissection. Eur J Cardiothorac Surg. 2018;53(3):525–530. doi:10.1093/ejcts/ezx281.
27.
KreibichMSiepeMBergerT, et al. The frozen elephant trunk technique for the treatment of type B and type non-A non-B aortic dissection. Eur J Vasc Endovasc Surg. 2021;61(1):107–113. doi:10.1016/j.ejvs.2020.08.040.
28.
KangWCShinEKParkCH, et al. Hybrid endovascular repair for aortic arch pathology: intermediate outcomes and complications: a retrospective analysis. Catheter Cardiovasc Interv. 2013;82(2):275–282. doi:10.1002/ccd.24384.
29.
Chassin-TrubertLMandelliMOzdemirBA, et al. Midterm follow-up of fenestrated and scalloped physician-modified endovascular grafts for zone 2 TEVAR. J Endovasc Ther. 2020;27(3):377–384. doi:10.1177/1526602819881128.
30.
PreventzaOLiaoJLOliveJK, et al. Neurologic complications after the frozen elephant trunk procedure: a meta-analysis of more than 3000 patients. J Thorac Cardiovasc Surg. 2020;160(1):20–33. doi:10.1016/j.jtcvs.2019.10.031.
31.
BobadillaJLWynnMTeferaG, et al. Low incidence of paraplegia after thoracic endovascular aneurysm repair with proactive spinal cord protective protocols. J Vasc Surg. 2013;57(6):1537–1542. doi:10.1016/j.jvs.2012.12.032.
DijkstraMLVainasTZeebregtsCJ, et al. Editor’s choice – spinal cord ischaemia in endovascular thoracic and thoraco-abdominal aortic repair: review of preventive strategies. Eur J Vasc Endovasc Surg. 2018;55(6):829–841. doi:10.1016/j.ejvs.2018.02.002.
34.
KärkkäinenJMCirillo-PennNCSenI, et al. Cerebrospinal fluid drainage complications during first stage and completion fenestrated-branched endovascular aortic repair. J Vasc Surg. 2020;71(4):1109–1118. doi:10.1016/j.jvs.2019.06.210.
35.
ChenXWangJPremaratneS, et al. Meta-analysis of the outcomes of revascularization after intentional coverage of the left subclavian artery for thoracic endovascular aortic repair. J Vasc Surg. 2019;70(4):1330–1340. doi:10.1016/j.jvs.2019.03.022.
36.
ZoliSRoderFEtzCD, et al. Predicting the risk of paraplegia after thoracic and thoracoabdominal aneurysm repair. Ann Thorac Surg. 2010;90(4):1237–1244; discussion 1245. doi:10.1016/j.athoracsur.2010.04.091.
37.
HaensigMSchmidtAStaabH, et al. Endovascular repair of the thoracic or thoracoabdominal aorta following the frozen elephant trunk procedure. Ann Thorac Surg. 2020;109(3):695–701. doi:10.1016/j.athoracsur.2019.07.011.
38.
KreibichMBergerTRylskiB, et al. Aortic reinterventions after the frozen elephant trunk procedure. J Thorac Cardiovasc Surg. 2020;159(2):392–399. doi:10.1016/j.jtcvs.2019.02.069.
39.
BergerTWeissGVoetschA, et al. Multicentre experience with two frozen elephant trunk prostheses in the treatment of acute aortic dissectiondagger. Eur J Cardiothorac Surg. 2019;56(3):572–578. doi:10.1093/ejcts/ezz037.
40.
Di MarcoLPantaleoALeoneA, et al. The frozen elephant trunk technique: European Association for Cardio-Thoracic Surgery position and bologna experience. Korean J Thorac Cardiovasc Surg. 2017;50(1):1–7. doi:10.5090/kjtcs.2017.50.1.1.
41.
LeoneABeckmannEMartensA, et al. Total aortic arch replacement with frozen elephant trunk technique: results from two European institutes. J Thorac Cardiovasc Surg. 2020;159(4):1201–1211. doi:10.1016/j.jtcvs.2019.03.121.
42.
PanXDLiBMaWG, et al. Endovascular repair of residual intimal tear or distal new entry after frozen elephant trunk for type A aortic dissection. J Thorac Dis. 2017;9(3):529–536. doi:10.21037/jtd.2017.03.04.
43.
LoschiDMelloniAGrandiA, et al. Open or endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology after frozen elephant trunk: perioperative and mid-term outcomes. Eur J Cardiothorac Surg. 2021;61(1):120–129. doi:10.1093/ejcts/ezab335.
44.
PichlmaierMATeebkenOEKhaladjN, et al. Distal aortic surgery following arch replacement with a frozen elephant trunk. Eur J Cardiothorac Surg. 2008;34(3):600–604. doi:10.1016/j.ejcts.2008.05.038.
45.
HoJYKChowSCYKwokMWT, et al. Total aortic arch replacement and frozen elephant trunk. Semin Thorac Cardiovasc Surg. 2021;33(3):656–662. doi:10.1053/j.semtcvs.2020.11.016.
46.
CoselliJSRoselliEEPreventzaO, et al. Total aortic arch replacement using a frozen elephant trunk device: results of a 1-year US multicenter trial [published online ahead of print September 6, 2022]. J Thorac Cardiovasc Surg. doi:10.1016/j.jtcvs.2022.08.029.
47.
KärkkäinenJMTenorioERJainA, et al. Outcomes of target vessel endoleaks after fenestrated-branched endovascular aortic repair. J Vasc Surg. 2020;72(2):445–455. doi:10.1016/j.jvs.2019.09.055.
48.
DiamondKRSimonsJPCrawfordAS, et al. Effect of thoracoabdominal aortic aneurysm extent on outcomes in patients undergoing fenestrated/branched endovascular aneurysm repair. J Vasc Surg. 2021;74(3):833–842. doi:10.1016/j.jvs.2021.01.062.
49.
LeursLJHarrisPLButhJ, et al. Secondary interventions after elective endovascular repair of degenerative thoracic aortic aneurysms: results of the European collaborators registry (EUROSTAR). J Vasc Interv Radiol. 2007;18(4):491–495. doi:10.1016/j.jvir.2007.01.018.
50.
RicottaJJ2nd. Endoleak management and postoperative surveillance following endovascular repair of thoracic aortic aneurysms. J Vasc Surg. 2010;52(4)(suppl):91S–9S. doi:10.1016/j.jvs.2010.06.149.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
