Thoracoabdominal aortic aneurysm repair after frozen elephant trunk procedure†

OBJECTIVES To evaluate the feasibility and the outcomes of second-stage thoracoabdominal (TA) repair after previous frozen elephant trunk (FET) implantation. METHODS Between 2005 and 2013, 41 patients underwent open TA aortic repair in our institution. Of these, 9 patients (78% male) underwent second-stage TA repair after previous FET implantation. Feasibility and outcomes were evaluated. RESULTS The mean interval between FET implantation and second-stage TA repair was 423 days (19-1979 days). Indications for second-stage TA repair were progression in aortic diameter of atherosclerotic aneurysms in the downstream segments in 6 patients, diameter progression in post-dissection aneurysms in 2 patients and giant cell aortitis with aneurysm formation in another patient. There were no in-hospital deaths. The median intensive care unit stay was 3.5 days (range: 1-12 days) and median hospital stay was 22 days (range: 14-132 days). We did not observe symptomatic spinal cord ischaemia or stroke. One patient (11%) developed acute renal failure requiring haemodialysis. CONCLUSION Second-stage TA aortic repair after previous frozen elephant implantation is a feasible and effective treatment modality for patients with various pathologies of downstream aortic segments. This approach adds additional value to the conventional elephant trunk technique by providing an excellent landing zone not only for additional stent graft procedures but also for subsequent open TA repai

Repair of stent graft-induced retrograde type A aortic dissection using the E-vita open prosthesis†

OBJECTIVES Stent graft-induced retrograde type A dissection is a life-threatening complication after endovascular treatment of acute aortic type B dissections. METHODS From August 2005 to February 2011, retrograde aortic dissection occurred in 4 of 29 patients (13.8%) undergoing thoracic endovascular aortic repair (TEVAR) for acute complicated aortic type B dissection. Three patients underwent emergent surgical conversion immediately after TEVAR. The operative strategy was a combined surgical and endovascular approach (frozen elephant trunk technique) using a specially designed hybrid prosthesis (Jotec E-vita open). All operations were performed under moderate hypothermia (25-28°C) and selective bilateral antegrade cerebral perfusion. The mean duration of circulatory arrest was 56±7min. Operative data and the outcome of surgery were analysed retrospectively. Data were analysed retrospectively in the limited number of patients. RESULTS All patients survived the surgical procedure. No stroke, paraplegia, renal failure or other major complications occurred. Postoperative CT scans revealed perigraft thrombus formation and stable aortic dimensions in all patients after 6 months. In one patient, the retrograde dissection remained primarily undetected and untreated. The patient died suddenly, with no clinical signs, within 7 days after stent graft implantation. Autopsy revealed cardiac tamponade due to retrograde type A aortic dissection. CONCLUSIONS Retrograde aortic dissection type A is a serious complication of thoracic endovascular repair of acute aortic type B dissection. Despite the small number of patients investigated in this study, the frozen elephant trunk technique appears to be a feasible bail-out strategy for the treatment of these acute aortic event

The location of the primary entry tear in acute type B aortic dissection affects early outcome†

OBJECTIVES The goal of the retrospective study was to relate the site of the primary entry tear in acute type B aortic dissections to the presence or development of complications. METHODS A consecutive series of 52 patients referred with acute type B aortic dissection was analysed with regard to the location of the primary entry tear (convexity or concavity of the distal aortic arch) using the referral CT scans at the time of diagnosis. These findings were related to the clinical outcome as well as to the need for intervention. RESULTS Twenty-five patients (48%) had the primary entry tear located at the convexity of the distal aortic arch, whereas 27 patients (52%) had the primary entry tear located at the concavity of the distal aortic arch. Twenty per cent of patients with the primary entry tear at the convexity presented with or developed complications, whereas 89% had or developed complications with the primary entry tear at the concavity (P<0.001). Furthermore, in patients with complicated type B aortic dissection, the distance of the primary entry tear to the left subclavian artery was significantly shorter as in uncomplicated patients (8 vs. 21mm; P=0.002). In Cox regression analysis, a primary entry tear at the concavity of the distal aortic arch was identified as an independent predictor of the presence or the development of complicated type B aortic dissection. CONCLUSIONS A primary entry tear at the concavity of the aortic arch as well as a short distance between the primary entry tear and the left subclavian artery are frequently associated with the presence or the development of complicated acute type B aortic dissection. These findings shall help us to further differentiate acute type B aortic dissections in addition to the common categorization in complicated and uncomplicated. These findings may therefore also have an impact on primary treatmen

Thoracoabdominal aortic aneurysm repair after frozen elephant trunk procedure

OBJECTIVES: To evaluate the feasibility and the outcomes of second-stage thoracoabdominal (TA) repair after previous frozen elephant trunk (FET) implantation. METHODS: Between 2005 and 2013, 41 patients underwent open TA aortic repair in our institution. Of these, 9 patients (78% male) underwent second-stage TA repair after previous FET implantation. Feasibility and outcomes were evaluated. RESULTS: The mean interval between FET implantation and second-stage TA repair was 423 days (19-1979 days). Indications for second-stage TA repair were progression in aortic diameter of atherosclerotic aneurysms in the downstream segments in 6 patients, diameter progression in post-dissection aneurysms in 2 patients and giant cell aortitis with aneurysm formation in another patient. There were no in-hospital deaths. The median intensive care unit stay was 3.5 days (range: 1-12 days) and median hospital stay was 22 days (range: 14-132 days). We did not observe symptomatic spinal cord ischaemia or stroke. One patient (11%) developed acute renal failure requiring haemodialysis. CONCLUSION: Second-stage TA aortic repair after previous frozen elephant implantation is a feasible and effective treatment modality for patients with various pathologies of downstream aortic segments. This approach adds additional value to the conventional elephant trunk technique by providing an excellent landing zone not only for additional stent graft procedures but also for subsequent open TA repair

Repair of stent graft-induced retrograde type A aortic dissection using the E-vita open prosthesis

Stent graft-induced retrograde type A dissection is a life-threatening complication after endovascular treatment of acute aortic type B dissections

The location of the primary entry tear in acute type B aortic dissection affects early outcome

The goal of the retrospective study was to relate the site of the primary entry tear in acute type B aortic dissections to the presence or development of complications

Long-Term Results with 187 Frozen Elephant Trunk Procedures

The frozen elephant trunk (FET) technique is an established therapeutic option in the treatment of complex aortic diseases. We report our long-term clinical outcomes after FET repair. A total of 187 consecutive patients underwent FET repair at our department between 8/2005 and 3/2023. Indications included acute and chronic aortic dissections and thoracic aneurysms. Endpoints included operative morbidity and mortality, long-term survival, and the need for reinterventions. Operative mortality, spinal cord injury and permanent stroke rates were: 9.6%, 2.7% and 10.2%, respectively. At five years, overall survival was 69.9 ± 3.9% and freedom from aortic-related death was 82.5 ± 3.0%, whereas at ten years, overall survival was 53.0 ± 5.5% and freedom from aortic-related death was 75.8 ± 4.8%. Sixty-one reinterventions on the thoracic aorta were necessary. Freedom from secondary interventions at ten years was 44.7 ± 6.4% overall (63.1 ± 10.0% for acute dissections, 40.8 ± 10.3% for chronic dissections and 28.9 ± 13.1% for aneurysms, respectively). The high reintervention rate for chronic dissections and for aneurysms is related to the pre-existing aortic pathology. Late aortic growth of untreated segments with potentially fatal outcome occurs even after ten years, so careful annual follow-up is mandatory in this patient cohort