Frozen Elephant Trunk Procedure Research Articles

Aortic arch surgery for DeBakey type 1 aortic dissection in patients aged 60 years or younger.

Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study. The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta. Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score-matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172). In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes. ClinicalTrials.gov Identifier: NCT04831073.

Results of using thoraflextm hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital

Background: The aim of this study was to introduce and evaluate the early results after the frozen elephant trunk (FET) procedure with ThoraflexTM Hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital. Methods: This is a retrospective descriptive study of all acceptable patients after the frozen elephant trunk (FET) procedure with ThoraflexTM Hybrid prothesis at Viet Duc University Hospital from January 2021 to May 2023. Results: There were 21 patients with a male rate of 85.7% and an average age 58.2±10 years old (range 40–73). History of patients with hypertension: 19 (90.5%); post-dissection aortic aneurysm: 2 (9.5%) patients. By cause, the number of patients with thoracic aortic aneurysm was 03 (14.3%), acute aortic dissection type A was 16 (76.1%), and aortic dissection type B was 02 (9.5%). In which there were 16 cases of emergency surgery (76.1%). Replacement of the aortic arch was performed under moderate hypothermic (280 °C on average) circulatory arrest and bilateral selective antegrade cerebral perfusion with permanent monitoring of cerebral tissue oxygenation by the MASIMO machine. Average cardio-pulmonary bypass time, aortic cross clamp time, distal hypothermic circulatory arrest time, and operating time were 137,5±22,9 minutes; 86,3±17,6 minutes; 25,2±8,9 minutes; and 7,7±10,3 hours. The average ventilation time, length of intensive care unit stay, and hospital stay were 7,2±9,7 days, 18,8±20,7 days, and 19,9 ± 6,5 days. There was one patient with post-operative cerebrospinal fluid drainage. No patient had bleeding complications, recurrent nerve palsy, reoperation, or in-hospital mortality. Conclusion: The initial results after the frozen elephant trunk procedure with ThoraflexTM Hybrid prothesis for the treatment of complex aortic disease at Viet Duc University Hospital were safe, good, and feasible.

Frozen elephant trunk versus conventional proximal repair of acute aortic dissection type I.

The extent of surgery and the role of the frozen elephant trunk (FET) for surgical repair of acute aortic dissection type I are still subjects of debate. The aim of the study is to evaluate the short- and long-term results of acute surgical repair of aortic dissection type I using the FET compared to standard proximal aortic repair. Between October 2009 and December 2016, 172 patients underwent emergent surgery for acute type I aortic dissection at our center. Of these, n = 72 received a FET procedure, while the other 100 patients received a conventional proximal aortic repair. Results were compared between the two surgery groups. The primary endpoints included 30-day rates of mortality and neurologic deficit and follow-up rates of mortality and aortic-related reintervention. Demographic data were comparable between the groups, except for a higher proportion of men in the FET group (76.4% vs. 60.0%, p = 0.03). The median age was 62 years [IQR (20), p = 0.17], and the median log EuroSCORE was 38.6% [IQR (31.4), p = 0.21]. The mean follow-up time was 68.3 ± 33.8 months. Neither early (FET group 15.3% vs. proximal group 23.0%, p = 0.25) nor late (FET group 26.2% vs. proximal group 23.0%, p = 0.69) mortality showed significant differences between the groups. There were fewer strokes in the FET patients (FET group 2.8% vs. proximal group 11.0%, p = 0.04), and the rates of spinal cord injury were similar between the groups (FET group 4.2% vs. proximal group 2.0%, p = 0.41). Aortic-related reintervention rates did not differ between the groups (FET group 12.1% vs. proximal group 9.8%, p = 0.77). Emergent FET repair for acute aortic dissection type I is safe and feasible when performed by experienced surgeons. The benefits of the FET procedure in the long term remain unclear. Prolonged follow-up data are needed.

Risk factors, prevention, and therapy of intraluminal stent thrombosis in frozen elephant trunk prostheses-what we know so far.

Intraluminal thrombus formation (ILT) is a recently discovered and highly clinically relevant complication after frozen elephant trunk implantation in cardiovascular surgery. In this phenomenon, a thrombus forms within the lumen of the stent graft component of the frozen elephant trunk prosthesis and puts the patient at risk for downstream embolization with visceral or lower limb ischemia. Incidence of ILT reported in the currently available studies ranges from 6% to 17% of patients after frozen elephant trunk implantation. Adverse thromboembolic events include acute occlusion of the celiac and superior mesenteric arteries, both renal arteries as well as acute lower limb ischemia due to iliac or femoral artery embolization that not infrequently require interventional or open embolectomy. Therefore, the presence of ILT is associated with increased short-term mortality and morbidity. Currently proposed strategies to avoid ILT formation include a more aggressive anticoagulation management, minimization of postoperative coagulation factor application, and even technical optimizations of the stent graft portion itself. If ILT is manifested, the therapeutic strategies tested to date are long-term escalation of anticoagulation and early endovascular extension of the FET stent graft with overstenting of the intraluminal thrombus. The long-term efficiency of these prophylactic and therapeutic measures has yet to be proven. Nonetheless, all surgeons performing the frozen elephant trunk procedure must be aware of the risk of ILT formation to facilitate a timely diagnosis and therapy.

High-Grade Infection after Branched Endovascular Aortic Repair in Patient with Recent COVID-19 Hospitalization.

In the context of the COVID-19 pandemic, the global healthcare landscape has undergone significant transformations, particularly impacting the management of complex medical conditions such as aortic aneurysms. This study focuses on a 76-year-old female patient with a history of extensive cardiovascular surgeries, including aortic valve replacement, Bentall operation, and Frozen Elephant Trunk procedure, who presented with a type II thoracoabdominal aortic aneurysm post-COVID-19 recovery. A comprehensive frailty assessment using the Modified Frailty Index and a two-phase endovascular approach for aneurysm treatment, considering the patient's frailty and complex medical history was performed. Upon successful aneurysm management, the patient's postoperative course was complicated by COVID-19 reinfection and Enterococcus faecalis superinfection, highlighting the increased risk of bacterial superinfections and the challenges posed by antimicrobial resistance in COVID-19 patients. The study underscores the necessity of vigilant postoperative surveillance and a multidisciplinary approach in managing such complex cases, highlighting the importance of personalized care strategies, integrating cardiovascular and infectious disease management, and adapting healthcare practices to the unique challenges of the pandemic. This case contributes to the evolution of knowledge on managing aortic aneurysms in the COVID-19 era, advocating for patient-centric treatment approaches and continuous research into long-term patient outcomes.

Evidence-based frozen elephant trunk practice: a narrative review.

The frozen elephant trunk (FET) allows a single-stage repair of complex arch pathologies due to its stented and non-stented hybrid prosthesis (HP) features. FET inherently has its own related complications including distal stent graft-induced new entry (dSINE), failure of aortic remodelling, endoleak, reintervention, and kinking of the stent. The aim of this narrative review is to discuss the latest evidence regarding the postoperative clinical outcomes of the FET procedure. Another aim is to provide an overview of results achieved using different FET devices on the global arch prostheses market. A comprehensive literature search was conducted using multiple electronic databases to identify and extract the relevant data and information. This review found that the literature reported a 5-12% mortality rate post-FET, with varying figures depending on the prosthesis type. Between 0-18.2% of patients developed dSINE, while 0.1-28% developed endoleak. Reintervention occurred in 0-28% of patients and the incidence of kinking has been quoted between 0-8% in the literature. Reporting aortic remodelling rates was challenging due to the lack of standardisation and various measurements reported; however, all studies included in this review reported relative increase in true lumen diameter, reduction in the false lumen diameter, and/or false lumen thrombosis. In conclusion, FET can achieve a favourable postoperative profile in terms of survival, complications and aortic remodelling, and remains the gold-standard treatment for thoracic aortic pathologies implicating the arch and descending thoracic aorta.

Abstract 18441: Long-Term Outcomes of Total Arch Replacement With Frozen Elephant Trunk Procedure for Patients With Acute Type A Aortic Dissection: A Single-Center Experience

Introduction: Total arch replacement (TAR) with frozen elephant trunk (FET) is an extensive surgical procedure for patients with acute type A aortic dissection (ATAAD). This study aimed to investigate the long-term outcomes of TAR with FET procedure for patients with ATAAD. Methods: A total of 670 patients with ATAAD who underwent TAR with FET procedure between January 2013 and December 2018 were included in this study. The patients were divided into two groups: the early group (n=245, 2013-2015) and the modern group (n=425, 2016-2018). In-hospital and long-term outcomes were compared between the two groups. Results: The average age and gender distribution were similar between the two groups (P>0.05). The modern group had a higher prevalence of preoperative coma (P<0.001). Patients in the modern group had a shorter mean duration of surgical procedure, including cardiopulmonary bypass time (189.8 ± 53.0 vs 176.0 ± 53.0 min, P=0.001) and hypothetical cardiac arrest time (22.8 ± 5.2 vs 15.1 ± 6.2 min, P<0.001). Although the in-hospital mortality was lower in the modern group, the difference was not statistically significant (6.1% vs 3.3%, P=0.064). The modern group had a significantly lower incidence of postoperative major adverse outcomes compared to the early group (33.9% vs 20.2%, P<0.001). The mean follow-up period was similar between the two groups. The overall long-term survival rate of patients undergoing TAR with FET procedure in this cohort was 92.7%. Patients in the modern group had a significantly lower cumulative incidence of all-cause mortality compared to those in the early group (P<0.001). Cox regression analysis showed that the modern year was an independent protective factor for the long-term survival of ATAAD patients undergoing TAR with FET procedure (HR=0.336, 95% CI: 0.193-0.585, P<0.001). Conclusions: The in-hospital and long-term outcomes of TAR with FET procedure for patients with ATAAD are promising and have improved over time.

Abstract 18173: Spinal Cord Protective Strategy Before Extensive Surgical Procedure for Patients With Acute Type A Aortic Dissection

Introduction: Spinal cord injury (SCI) is a devastating complication following total arch replacement (TAR) with frozen elephant trunk (FET) procedure in acute type A aortic dissection (ATAAD). This study aims to evaluate the efficacy of spinal cord protective strategy (SCPS) implemented before this extensive procedure. Methods: Between January 2013 and December 2021, a total of 1105 ATAAD patients underwent TAR with FET procedure. SCPS included preoperative assessment of segment number of the false lumen closest to the spinal cord between T9-L3 level. If segment number exceeded 5, indicating high risk of postoperative SCI, prophylactic cerebrospinal fluid drainage would be conducted. SCPS was performed since June 2017 at our institution (703 patients). The remaining 402 patients were served as the control group. The two groups were compared to assess the efficacy of SCPS in preventing SCI. Results: The average age was significantly higher in the SCPS group (48.9±11.1 vs 46.6±10.0, P<0.001). The patients in SCPS group presented with higher percentage of coma (P<0.001). The mean duration of cardiopulmonary bypass was significantly longer in SCPS group (P<0.001), while the mean duration of hypothetical cardiac arrest was significantly lower (P<0.001). Propensity score matching was conducted, resulting in a matched sample of 186 patients from each group to adjust for differences in patient characteristics. The incidence of postoperative SCI was significantly lower in SCPS group (1.7% vs 7.2%, P<0.001). Propensity score matching demonstrated higher estimated incremental protective efficacy of SCPS (1.1% vs 9.7%, P<0.001). Multivariate logistic regression analysis revealed that preoperative SCPS was an independent protective factor for postoperative SCI (OR=0.226, 95% CI: 0.114-0.448, P<0.001). Conclusions: The implementation of preoperative SCPS is an effective strategy for reducing the incidence of SCI follow extensive surgical procedure in ATAAD.

Surgical bypass to the left subclavian artery: an extra-anatomical transpleural approach

A distal anastomosis in zone 3 is technically demanding during the frozen elephant trunk procedure. Proximalization of the distal anastomosis to zone 2 with subsequent revascularization of the left subclavian artery is an attractive alternative. This video tutorial describes the technique of an extra-anatomical bypass from the aortic prosthesis to the infraclavicular left subclavian (axillary) artery in arch replacement with the distal aortic graft anastomosis in zone 2.

Frozen elephant trunk technique using hybrid grafts: 15-year outcomes from a single-centre experience.

The purpose of the study is to compare the short- and long-term outcomes of the frozen elephant trunk (FET) technique based on 2 different hybrid grafts implanted from January 2007 to July 2022. The study includes patients who underwent an elective or emergency FET procedure. Short-term, long-term mortality and freedom from thoracic endovascular aortic repair (TEVAR) were the primary end points. Analyses were carried out separately for the periods 2007-2012 and 2013-2022. Of the 367 enrolled, 49.3% received E-Vita Open implantation and 50.7% received Thoraflex Hybrid implants. Overall mean age was 61 years [standard deviation (SD) = 11] and 80.7% were male. The average annual volume of FET procedures was 22.7 cases/year. Compared to E-Vita Open, patients implanted with Thoraflex Hybrid grafts were more likely to receive distal anastomosis in zone 2 (68.3% vs 11.6%, P < 0.001) with a shorter stent portion, mean = 103mm (SD = 11.3) vs mean = 149 mm (SD = 12.7; P < 0.001) and they underwent a reduced visceral ischaemia time, mean = 42.5 (SD = 14.2) vs mean= 61.0 (SD = 20.2) min, P < 0.001. In the period 2013-2022, overall survival at 1, 2 and 5 years was 74.8%, 72.5% and 63.2% for Thoraflex and 73.2%, 70.7% and 64.1% for E-Vita, without significant differences between groups (log-rank test = 0.01, P = 0.907). Overall freedom from TEVAR at 1, 2 and 5 years was 66.7%, 57.6% and 39.3% for Thoraflex and 79%, 69.7% and 66% for E-Vita, with significant differences between groups (log-rank test = 5.28, P = 0.029). In a competing risk analysis adjusted for chronic/residual aortic syndromes and stent diameter, the Thoraflex group was more likely to receive TEVAR during follow-up (subdistribution hazard ratio SHR = 2.12, 95% confidence interval 1.06-4.22). The FET technique addresses acute and chronic arch disease with acceptable morbidity and mortality. Downstream endovascular reinterventions are very common during follow-up.

The Frozen Elephant Trunk Procedure Using New Russian Hybrid Prosthesis "Soft Elephant Trunk": the Early Experience.

Aim To present the first experience of performing the Frozen Elephant Trunk (FET) surgery in patients with thoracic aorta disease using a new Russian hybrid stent graft "Soft Elephant Trunk".Material and methods Between 2014 and 2021, 170 patients with thoracic aortic disease underwent complete aortic arch replacement using the FET technique. In 70 of these cases (since June 2019), a hybrid graft "Soft Elephant Trunk" was used. A specific feature of this graft is the conical reduction of the radial force of nitinol crowns and the soft distal end without radial force. The study endpoints were early postoperative results, as well as the absence of reoperations on the aorta, absence of stent-graft-associated complications, including distal stent-graft-induced fenestration, and survival at a mid-term follow-up of up to 2.5 years.Results Interventions were performed in patients with A type aortic dissection (n=51; 72.9 %), type B aortic dissection (n=13; 18.6 %), and thoracoabdominal aortic aneurysm (TAAA) (n=6; 8.5 %). In 14 (20 %) of these cases, interventions were performed after a primary intervention on the proximal aorta. Acute aortic dissection was diagnosed in 17 (24.3 %) cases. Aortic root replacement was performed in 21 (30 %) cases, David procedure in 5 (7.2 %) cases, Bentall-DeBono procedure in 11 (15.7 %) cases, and supracoronary graft placement in 33 (47.1 %) cases. There were no cases of paraplegia or paraparesis. Respiratory insufficiency was observed in 8 (11.4%) cases. In one (1.4%) case, acute renal failure developed, which required renal replacement therapy. In-hospital mortality was 4.3 % (3 patients died). Mean follow-up duration was 9 [4.25; 16] months. Three-year survival was 94 % (95 % confidence interval, CI: 88-99.9) and absence of reoperation was 96.6 % (95 % CI: 90.1-100). There were no cases of distal stent-graft-induced fenestration in this group.Conclusion The new hybrid graft, due to its specific structure, provides prevention of distal stent-graft-induced fenestration and, thereby, a stable long-term result. Using this stent-graft is effective in patients with thoracic aorta pathology undergoing the FET surgery. However, further studies are needed to determine potential advantages and disadvantages of this new hybrid graft, to obtain long-term results and accumulate experience.

Early and long-term outcomes of young adult patients ≤30 years old with acute type A aortic dissection.

The aim of this study was to investigate the early and long-term outcomes after total arch replacement (TAR) and frozen elephant trunk (FET) implantation in adult patients ≤30 years with acute type A aortic dissection (ATAAD). All young adult patients (≤30 years) with ATAAD who underwent TAR and FET between 2009 and 2017 were enrolled. The end points were major organ morbidity and mortality, aortic-related events and reoperation. The mean age of all 83 patients was 25.9 (standard deviation, 3.3) years. The in-hospital mortality was 9.64% (8/83), and 9 (10.8%) patients required re-exploration for bleeding. The aortic-related events risk was 42.7% (32/75) and the aortic reoperation risk was 17.3% (13/75). Overall survival was 85.5% [95% confidence interval (CI), 75.9-91.5%] at 5 years and 75.9% (95% CI, 63.3-84.7%) at 10 years. The cumulative incidence of aortic-related events was 35% (95% CI, 24-47%) at 5 years and 58% (95% CI, 36-75%) at 10 years; the cumulative reoperation rate was 15% (95% CI, 7.9-24%) at 5 years and 17% (95% CI, 9.2-27%) at 10 years. Marfan syndrome significantly increased the aortic-related events (P = 0.036) and reoperation (P = 0.041) risks. Despite extensive repair in young ATAAD patients, the late aortic dilatation and reoperation risk remain high. The TAR and FET procedures achieved satisfactory early outcomes and reduced late aortic dilatation and reoperation in young patients compared with other records. Close follow-up and aggressive early reintervention are essential for patients with aortic-related risk factors early in life.

Open surgical treatment for aortic arch and coronary artery aneurysms associated with immunoglobulin G4-related disease: a case report

BackgroundImmunoglobulin G4-related disease (IgG4RD) is a systemic autoimmune disease characterized by a dense lymphoplasmacytic infiltrate containing IgG4-positive plasma cells that can cause aneurysms in various organs and tissues. There have been many reports of IgG4RD aneurysms; however, the surgical procedures adopted remain controversial. Herein, we report a case in which surgical treatment for IgG4-related aneurysms was successful.Case presentationAn 83-year-old woman with IgG4-related disease developed multiple aneurysms, including thoracic aortic aneurysm (TAA), right coronary artery aneurysm (CAA), abdominal aortic aneurysm, and common iliac artery aneurysm. Enhanced computed tomography (CT) revealed progressive enlargement of the TAA, while positron emission tomography-CT revealed intense 18F-fluorodeoxyglucose uptake around the TAA and CAA, suggesting the presence of adhesive tissue caused by adventitial inflammation around the aneurysms. Open aortic arch replacement with frozen elephant trunk procedure and coronary artery bypass grafting with ligation of the coronary artery were performed to treat the TAA and CAA. No surgical complications occurred. The postoperative CT scan showed no endoleak around the open stent graft and the coronary artery was patent. The patient is being followed up on an outpatient basis after discontinuing steroid therapy.ConclusionsWe report the successful surgical treatment of IgG4-related multiple aneurysms. Our findings reveal that the main site of inflammation in aneurysms of IgG4RD is the adventitia and the frozen elephant trunk procedure is useful for avoiding complications.

Management of the left subclavian artery during aortic arch replacement using a frozen elephant trunk approach: a review.

The frozen elephant trunk (FET) technique for total aortic arch replacement extends repair into the proximal portion of the descending thoracic aorta. Several techniques and modifications of total arch replacement have been described in the literature, and many of these iterations are related to facilitating the distal anastomosis while preserving flow to the left subclavian artery (LSCA), as well as maintaining posterior circulation of the brain via the vertebral artery, by reducing the circulatory arrest time during reconstruction. Because of the LSCA's posterior and deep anatomic location in the chest, particularly in obese patients, this revascularization is often challenging; additional concerns regarding LSCA revascularization include patients with large aortic arch aneurysms, those with dissected or calcified arteries, and reoperation. A careful plan for reconstruction is necessary. Whether revascularization is performed preoperative, intraoperative, or postoperatively, every effort should be made to include the left subclavian artery as part of the operational approach. Revascularization techniques include reimplantation as part of the island patch or direct anastomosis, stenting, bypass, transposition or a hybrid approach. The importance of maintaining circulation of the LSCA cannot be overstated. Preserving flow to the spinal cord via collaterals minimizes the risk of cord injury during FET procedure. In patients with a patent left internal mammary artery bypass, left arm arteriovenous fistula for hemodialysis, dominant circulation, or direct aortic origin of the left vertebral artery, revascularization is necessary as well. In the case of initial sacrifice, arm claudication or steal syndrome usually dictates delayed extra-anatomic revascularization in the postoperative period.

Distal stent graft – induced new entry after frozen elephant trunk procedure for type a aortic dissection: two cases report

Objectives: We report two clinical cases that wherein stent graft-induced new entry (dSINE) after frozen elephant trunk (FET) procedure for type A aortic dissection were resolved successfully by additional stent graft placement.&#x0D; Methods: Describe rare clinical cases.&#x0D; Results: Two patients were hospitalized after FET procedure for type A aortic dissection treatment. The former had refractory abdominal pain and the latter had sudden chest pain; both their abdominal thoracic CT scanner showed dSINE. We decided to place additional stent grafts to cover the new entry. Both patients recovered well and were discharged after 5 and 12 days, respectively, without any significant complications.&#x0D; Conclusions: Supplemental stent graft placement is an effective and safe treatment choice for dSINE post-FET procedure.

Five-Year Outcomes of Hybrid Arch Frozen Elephant Trunk Repair With Novel Multibranched Hybrid Graft

BackgroundThe objective of this study was to report the 5-year outcomes of hybrid arch frozen elephant trunk (FET) procedures with a multibranched hybrid graft. MethodsBetween 2014 and 2020, 50 consecutive patients (63 ± 15 years old; 34% women) underwent hybrid arch FET with Thoraflex hybrid graft (Terumo Aortic) at a single center. Indications included aortic aneurysm (n = 48 [96%]), acute aortic dissection (n = 10 [20%]), and chronic dissection (n = 20 [40%]). Follow-up was complete, and mean follow-up was 1455 ± 664 days. ResultsAll 50 patients experienced successful device implantation. The 30-day/in-hospital mortality was 2% (n = 1). Stroke and transient neurologic deficits occurred in 1 patient (2%) and 3 patients (6%). Two patients (4%) and 1 patient (2%) experienced transient and permanent spinal cord ischemia. FET thromboembolic complication was observed in 1 patient (2%). In follow-up, 6 patients died of aortic events, and there were 13 reinterventions in the downstream aorta, of which 46% (6/13) were planned second-stage operations. Survival rate at 1 year, 2 years, and 5 years was 96%, 92%, and 85%, and freedom from unplanned distal reintervention at 1 year, 2 years, and 5 years was 98%, 92%, and 81%. Computed tomography follow-up demonstrated positive distal aortic remodeling with aneurysmal regression and stabilized aortic dimensions in patients with aortic dissection. ConclusionsThe hybrid arch FET procedure with a novel hybrid graft is associated with good early and midterm outcomes. Longer term outcomes merit further investigation.

Thoracoscopic Clipping of Intercostal Artery for Treatment of Type II Endoleak Following Frozen Elephant Trunk Procedure: Case Report.

A 38-year-old man with history of Crawford extent I thoracoabdominal aneurysm and chronic type B1,10 aortic dissection underwent a hybrid repair using the frozen elephant trunk technique. The patient was followed up annually, and type II endoleak of the descending thoracic aorta was diagnosed, leading to negative aortic remodeling. The endoleak was managed by performing intercostal artery clipping using minimally invasive thoracoscopic technique under transesophageal echocardiography control. The computed tomography scan showed no endoleak and complete false-lumen thrombosis with positive remodeling in the distal aortic segments.

Fracture and embolization of a metal stent after a frozen elephant trunk procedure.

The Frozenix J graft open stent graft has been available since 2014 in Japan. This stent is widely used for the frozen elephant trunk technique in many institutions, mainly for cases of acute type A aortic dissection and also for cases of a true aneurysm and chronic aortic dissection. We treated a rare case in which the metal wires of the Frozenix J graft were broken and embolized to the periphery half a year after being implanted.

Frozen elephant trunk technique for aortic arch surgery: the Bordeaux University Hospital experience with Thoraflex hybrid prosthesis.

Aortic arch surgery still represents a challenge, and the frozen elephant trunk (FET) allows a one-step surgery for complex aortic diseases. The aim of the study was to analyze the results of patients undergoing FET procedure for aortic arch surgery at Bordeaux University Hospital. Patients undergoing FET procedure for multisegmented aortic arch pathologies were analyzed in this single-center retrospective study. Further subgroup analyses were performed according to the degree of urgency of the operation (elective versus emergent surgery) and cerebral protection technique: bilateral selective antegrade cerebral perfusion (B-SACP) versus the unilateral one (U-SACP), regardless of the degree of urgency. From August 2018 to August 2022, 77 consecutive patients (64.1±9.9 years, 54 males) were enrolled: 43 (55.8%) for elective surgery and 34 (44.2%) in emergency. Technical success was 100%. 30-day mortality was 15.6% (N.=12, 7% elective vs. 26.5% emergent, P=0.043). Six (7.8%) non-disabling strokes occurred (1.9% B-SACP vs. 20% U-SACP, P=0.021). Median follow-up was 1.11 years (interquartile range, 0.62-2.07). The 1-year overall survival was 81.6±4.45%. The elective group showed a survival trend when compared to the emergency one (P=0.054). However, further examination at landmark analysis elective surgery showed a better survival trend compared to emergency surgery up to 1.78 years (P=0.034), after which significance was lost (P=0.521). Thoraflex hybrid prosthesis for FET technique demonstrated feasibility and satisfactory short-term clinical outcomes, even in emergent settings. In our practice B-SACP seems to offer better protection and less neurological complications compared to U-SACP, nevertheless further analyses are warranted.

Distal Stent Graft-Induced New Entry After Frozen Elephant Trunk Procedure for Aortic Dissection

The purpose of this study was to evaluate the risk factors of distal stent graft-induced new entry (dSINE) after frozen elephant trunk (FET) procedure for aortic dissection (AD) and to consider strategies to prevent this complication. This retrospective review included 52 patients who had undergone aortic arch repair for AD with the FET procedure using J Graft FROZENIX from 2014 to 2020 at a single center. Baseline characteristics, aortic characteristics and mid-term outcomes were compared between patients with and without dSINE. The extent of unfolding of the device and movement of the distal edge of the device were analyzed by multidetector computed tomography. The primary endpoints were survival and freedom from reintervention. dSINE was the most prevalent complication after FET procedure, with an incidence of 23%. Eleven of 12 patients with dSINE underwent secondary interventions. dSINE was common in chronic aortic dissection (P=0.001) and was associated with the residual false lumen area (P<0.001) and movement distance of the distal edge of the device in the cranial direction (P<0.001). The distal edge of the FET is more likely to move in the cranial direction, and this movement may cause dSINE.