The Aortic Center Approach—Reinterventions after Frozen Elephant Trunk Surgery

Objectives: To demonstrate our aortic center approach and outcome after frozen elephant trunk (FET) procedures and reinterventions.

Methods: From October 2010 to August 2018, we performed 92 FET procedures at our center (58.7% male, age 63.3 ± 12.7, EuroSCORE II 13.2 ± 12.9%). Underlying pathologies were thoracoabdominal aneurysms in 38%, ruptured (8.7%), acute (18.5%), and chronic (22.8%) Type A dissections and Type B dissections in 12.0% of cases. Follow-up (507.3 ± 413.5 days) including computed tomography or magnetic resonance imaging was performed after 3 and 12 months and between 1 and 2 years thereafter depending on aortic pathology. The indication for reintervention was consented in an interdisciplinary case conference.

All procedural and follow-up data were collected, inserted into a dedicated database, and retrospectively analyzed.

Results: Procedural survival of the initial FET surgery was 98.9%. Overall 30-day survival was 84.8%.

Due to postoperative serial imaging, 32.1% (n = 25) of the 30-day survivors received aortic reinterventions after FET procedure.

Three patients underwent a Crawford procedure due to extensive residual dissection in two patients and a newly developed Type B dissection in one patient. All patients suffered from connective tissue disorder. The remaining 22 patients underwent thoracic endovascular repair (TEVAR).

In 11 patients with residual aortic dissections, TEVAR was performed to exclude false lumen perfusion, including implantation of a knickerbocker graft or a candy-plug graft in 7 patients. In another eight patients suffering from Type Ib endoleak due to extensive thoracoabdominal aneurysms, TEVAR procedure alone (six of eight) or TEVAR and Candy-Plug technique were necessary to seal the leak. After FET procedure for extensive dissection of the aorta, abdominal malperfusion occurred in two patients. This was successfully solved by fenestration of the dissection membrane in both cases. One case of abdominal aneurysm after repair of Type A dissection was treated by EVAR.

During the follow-up of 507.3 ± 413.5 days after reintervention, mortality rate was 8%.

Conclusion: Secondary interventions after FET procedures are more frequently required as expected due to the extensive aortic disease in this complex patient population.

To achieve satisfactory long-term survival rates, regular follow-up and a multidisciplinary Aortic Center approach is paramount as reinterventions affecting the whole aorta may become necessary.