Kinking of frozen elephant trunk: reality versus myth—a case report and literature reported
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ABSTRACT: Background
Kinking or iatrogenic stenosis in the frozen elephant trunk (FET) is a possible complication, however, there have been few cases reported. Case Description
A 43-year-old male with acute type A aortic dissection (ATAAD) underwent total arch replacement and FET installation. After weaning from the cardiopulmonary bypass, both femoral pulses were absent. A right axillo-bifemoral bypass using 8 mm graft was performed. Postoperative aortography showed a 100 mmHg-stenosis at the FET and 28 mm stent-graft was inserted to relieve stenosis. Eleven cases of postoperative FET stenosis have been reported from 2007 to 2019. The ages ranged from 30 to 72 years and 6 patients had ATAAD, 4 had chronic type A dissection, and 1 had non-dissection. They all underwent total arch replacement. To correct the iatrogenic stenosis of the FET, additional TEVAR was done in 8 patients, 2 had axillo-femoral bypass, 1 had a bare stent graft, and one required re-anastomosis. Conclusions
To prevent the FET kinking, surgeons should place the stented portion of the FET in the aortic arch angle. Also, we should make the non-stented portion as short as possible at the distal anastomosis. The DANE (distal anastomosis new entry) should be avoided by the secure anastomosis. Over-sizing or under-sizing of the FET should be minimized.
SUBMITTER: Okita Y
PROVIDER: S-EPMC9412205 | biostudies-literature | 2022 Aug
REPOSITORIES: biostudies-literature
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Project description:Treatment of aortic arch aneurysms and dissections require highly complex surgical procedures with devastating complications and mortality rates. Currently, repair of the complete arch until the proximal descending thoracic aorta consists of a two-stage procedure, called elephant trunk (ET) technique, or a single stage a single-stage technique referred to as frozen elephant trunk (FET). There is conflicting evidence about the perioperative results of ET in comparison with FET. We carried out a meta-analysis to investigate possible differences in perioperative and early (up to 30 days) outcomes of ET vs. FET, particularly for mortality, spinal cord injury (SCI), stroke, and renal failure. We also performed a meta-regression to explore the effects of age and sex as possible cofactors. Twenty-one studies containing data from interventions conducted between 1997 and 2019 and published between 2008 and 2021 with 3153 patients (68.5% male) were included. ET was applied to 1,693 patients (53.7%) and FET to 1460 (46.3%). Overall mortality after ET was 250/1693 (14.8%) and after FET 116/1460 (7.9%). Relative risk (RR) and 95% confidence interval (CI) were 1.37 [1.04 to 1.81], p = 0.027. There was no significant effect of age and sex. SCI occurrence after the second stage of ET was 45/1693 (2.7%) and after FET 70/1,460 patients (4.8%) RR 0.53 [0.35 to 0.81], p = 0.004. Age and sex were not associated with the risk of SCI. No significant differences were observed between ET and FET in the incidence of stroke and renal failure. Our results indicate that ET is associated with higher early mortality but lower incidence of SCI compared to FET. When studies published in the last 5 years were analyzed, no significant differences in mortality or SCI were found between ET and FET. This difference is attributed to a decrease in mortality after ET, as the mortality after FET did not change significantly over time.
| S-EPMC9630467 | biostudies-literature
Project description:Background and objectiveSince 2003, the Frozen Elephant Trunk (FET) technique has attained rising popularity for treating extensive aortic arch pathologies such as acute and chronic aortic dissection, as well as thoracic aortic aneurysm. Conventionally, the FET procedure included a complete resection of the aortic arch and, subsequently, a distal aortic anastomosis of the prosthetic part of the hybrid graft in arch zone 3. Simultaneous to the introduction of the FET technique, the traditional Elephant Trunk technique was simplified by adding debranching techniques which allows for proximalization of the distal aortic anastomosis. Nowadays, modern concepts of aortic arch surgery combine the FET technique with proximalization of the distal anastomosis in arch zone 2 or further proximal, achieved by using different debranching techniques. This review describes different debranching techniques to facilitate arch reconstruction, and aims to critically assess the outcomes and potential clinical advantages of proximalization using debranching in FET surgery.MethodsWe conducted a search using the PubMed and Google Scholar electronic databases to evaluate published outcomes of different debranching techniques. An overview of the data synthesis of 21 included studies is reported.Key content and findingsMost studies report numeric, but not statistically significant improved outcomes after debranching in FET surgery for mortality, neurological complications, spinal cord injury, kidney failure, bowel ischemia and recurrent nerve palsy. Some studies report statistically significant improved results in isolated endpoints such as neurological, bowel ischemia, and recurrent nerve palsy. Most studies report debranching to be technically easier, but this is difficult to objectively assess and measure.ConclusionsThere is an improved numeric outcome of different debranching techniques with proximalization of the distal anastomosis, but without reaching statistical significance. This review shows marked heterogeneity across included studies and highlights the scarce use of existing guidelines in clinical research of open aortic arch surgery as proposed by the International Aortic Arch Surgery Study Group. Furthermore, this review demonstrates the urgent need for multicenter registries or studies to be able to compare the outcome of different surgical techniques for various aortic arch pathologies.
| S-EPMC10423730 | biostudies-literature
Project description: Not available
| S-EPMC10315428 | biostudies-literature
Project description:We describe our technique for total aortic arch replacement with stenting of the descending thoracic aorta allowing normothermic cardiopulmonary bypass and avoiding hypothermic circulatory arrest.Supplementary informationThe online version contains supplementary material available at 10.1007/s12055-023-01536-1.
| S-EPMC10713948 | biostudies-literature
Project description:ObjectiveTraditional total arch replacement with frozen elephant trunk requires 2 separate grafts in the descending thoracic aorta and arch, and frequently requires a graft-to-graft anastomosis, which is prone to bleeding. The Thoraflex (Terumo Aortic) device treats the arch and descending thoracic aorta in a single device but has not been compared directly to traditional total arch replacement with frozen elephant trunk and has not been studied in a real-world context in the United States.MethodsA consecutive sample of total arch replacement with frozen elephant trunk patients across 5 different institutions between January 2018 and January 2024, identified 438 patients of which 83 out of 438 (18.9%) had a Thoraflex device. Propensity score matching in a 1:2 ratio identified 166 well-matched controls. Groups were compared across perioperative outcomes.ResultsOne hundred forty out of 438 (32%) patients presented with acute type A dissection, 112 out of 438 (26%) had an aneurysm, and 87 out of 438 (20%) had chronic dissection with a previous proximal repair. One hundred thirty-two out of 438 (30%) underwent surgery on an emergency or emergency/salvage basis. Median (interquartile range [IQR]) crossclamp times in the Thoraflex and traditional matched groups were 71 (IQR, 48-105) and 82 (IQR, 62-123), respectively, (P = .012). Total circulatory arrest times were 19 minutes (IQR, 13-32 minutes) and 23 minutes (IQR, 17-37 minutes), respectively (P = .009). Total procedure times were 6.1 hours (IQR, 5.2-7.3 hours) and 6.8 hours (IQR, 5.7-8.2 hours), respectively (P = .012). The operative mortality, stroke, and paralysis rates were 11 out of 83 (13%), 16 out of 83 (19%), and 4 out of 83 (5%), respectively, in the Thoraflex group and were not significantly different than matched controls.ConclusionsThe Thoraflex hybrid device facilitates shorter crossclamp and circulatory arrest times for arch replacement, with similar observed mortality and stroke rates compared with matched controls.
| S-EPMC11883694 | biostudies-literature
Project description:Background and objectiveThe 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.MethodsA comprehensive literature search was conducted using multiple electronic databases to identify and extract the relevant data and information.Key content and findingsThis 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.ConclusionsIn 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.
| S-EPMC10753235 | biostudies-literature
Project description:The development of the frozen elephant trunk (FET) prosthesis has revolutionised how we treat some of the most complex aortic pathology, including in the emergency setting of acute type A aortic dissection. The design of the prosthesis is fundamental to the success of the procedure in combination with the surgeon’s skill in interpreting the pre-operative scan and procedural planning to juggling the technical aspects of the deployment and reimplantation of the supra-aortic vessels. Furthermore, organ protection strategies and techniques to reduce the complications of neurological and renal impairment are paramount. This article focuses on the Thoraflex Hybrid prosthesis including the evolution of the concept, design features unique to the device and surgical technique including fundamentals of sizing and implantation steps with illustrations. The Thoraflex Hybrid prosthesis provides an ergonomic and neat delivery system with a trusted gelatin coated surgical graft material making implantation and use as straightforward as possible. These features have meant that the device is a market leader in the field of FETs with outcome data and implant figures to support its efficacy globally. The success of the device is also reflected in the literature. For example, in the UK study from Mariscalco et al., the mortality of FET implantation in acute type A dissection, of which most were using the Thoraflex device, was only 12%. This is comparable to leading centres in Europe with the inherent advantage of improving long-term outcomes in addition. Of course, this strategy is not appropriate in all cases and precise judgement of when to deploy a FET in both the emergency and elective setting is key to achieving good outcomes.
| S-EPMC10315425 | biostudies-literature
Project description:The treatment of complex multi-segment disease concomitantly affecting the aortic arch and descending thoracic aorta is technically challenging. Until the 1990s, such extensive pathology was addressed by median sternotomy for aortic arch replacement followed by a traumatic thoraco-abdominal incision for reconstruction of the descending aorta as a single- or two-stage procedure. The advent of the conventional elephant trunk procedure by Borst in 1983 simplified the second-stage of this procedure by eliminating the need for clamping of the descending thoracic aorta. However, graft-related complications and the considerable inter-stage mortality were significant limitations associated with the conventional elephant trunk procedure. The emergence of endovascular technology and availability of dedicated arch prostheses culminated in a major paradigm change with the introduction of the frozen elephant trunk (FET) concept by Kato and colleagues in the mid-1990s. This one-stage procedure permits concurrent total aortic arch replacement with antegrade delivery of a descending aortic stent-graft which itself functions as a proximal landing zone to facilitate prospective endovascular intervention to treat residual or de novo disease in the more distal aorta. The frozen elephant technique has been applied extensively in acute aortic dissection to restore true lumen patency, occlude descending aortic intimal tears and promote false lumen thrombosis, as well as for chronic degenerative arch aneurysms. The Thoraflex Hybrid and E-vita Open are the two most common commercially available hybrid FET prostheses. This review aims to discuss the development, indications, surgical technique, currently available prostheses, clinical outcomes and future directions regarding the FET procedure.
| S-EPMC9622409 | biostudies-literature
Project description:The increasing use of total arch replacement and frozen elephant trunk (FET) is expected to lead to an increase in the prevalence of graft infections requiring replacement involving an FET, which is generally a more invasive procedure than the initial surgery. Herein, we describe a novel method for FET removal using a polyvinyl tube as the storage device. The procedure is completed using the same median sternotomy approach as the initial surgery. We report on the outcomes for six patients. Our procedure is simple to perform and safe and caused no injury to the aorta in our case series.
| S-EPMC9016002 | biostudies-literature
Project description:Background: The frozen elephant trunk method combines the implantation of a Dacron prosthesis with a self-expanding stent graft, which allows for complex repairs of the aortic arch and thoracic aorta in one procedure. Despite the advantages of hybrid treatment for aortic arch aneurysms, in Poland, only a few such surgeries are performed annually compared to in Western countries. The aim of this study was to demonstrate the 8-year outcomes of treatment at the center where the Aortic Team operates, which is one of the centers in Poland with the most extensive experience in hybrid FET treatment. Methods: Patients who underwent frozen elephant trunk surgery for chronic and acute pathologies of the aortic arch and thoracic aorta between March 2016 and March 2024 were comprehensively analyzed retrospectively. Frozen elephant trunk procedures were performed under three consecutive clinical conditions: acute aortic dissection, chronic aortic dissection and redo surgery. Results: A total of 40 patients (median age: 60 years (53-66), 67.5% male) were admitted to our hospital and underwent an FET procedure. The median Euroscore II was 25.9% and the 30-day mortality was 7.5%. The 1-year and 5-year mortalities were the same, equal to 15%, with mortality cases observed only in the first and second groups of consecutive patients during the first two months of follow-up. Spinal cord injury was observed in 2.5% of patients. Conclusions: The FET technique can be successfully used to treat aortic aneurysms with optimal results and low complication rates. The surgery length, including the cardiopulmonary bypass and aortic cross-clamp times, decreased significantly with increasing experience.
| S-EPMC11547153 | biostudies-literature