Open Aortic Arch Repair by Frozen Elephant Trunk: Single-Center Experience in 300 Patients

Objectives: Frozen elephant trunk (FET) combines open surgical and endovascular skills for aortic arch and descending aorta repair. The study reports a single-center experience with FET in emergency and nonemergency multisegmental thoracic aortic disease.

Methods: Between February 2005 and August 2018, 300 consecutive patients (age mean ± SD 59 ± 11 years) underwent FET for acute aortic dissection (AAD, N = 164), chronic aortic dissection (CAD, N = 71), or multisegmental aortic aneurysm (AA, N = 65). Emergency treatment underwent 167 (56%) patients (152 AAD, 5 CAD, and 10 TAA) and was defined as surgery within 24 hours after admission for aortic-related symptoms. Fifty-six (19%) patients had previous sternotomy, 22 (7%) previous descending open or endo aortic repair, and 20 (7%) previous abdominal and peripheral arteries repair. Arch surgery was performed under selective cerebral perfusion (SCP) and hypothermic circulatory arrest (HCA). As FET, the E-vita open prosthesis was used in arch Zone 3 or in Zone ≤2 in combination with left subclavian artery debranching. In follow-up (100%, 3.9 ± 3.2 years), the residual aortic disease downstream was evaluated by repeated computed tomography.

Results: In 176 (59%) patients, a total of 253 concomitant aortic root and cardiac procedures were performed. A 30-day mortality was in total 12% (AAD 13%, CAD 8%, and AA 14%) without statistical difference between emergency (13%) versus nonemergency (10%) patients, p = 0.592. Multivariate analysis revealed peripheral artery disease (p = 0.003), chronic pulmonary disease (p = 0.023), CPB >240 minutes (p = 0.027), SCP >70 minutes (p = 0.022), and HCA >45 minutes (p = 0.006) as risk factors for mortality. FET in Zone ≤2 was associated with less SCP and HCA times (p < 0.001) and improved 5 years survival compared with Zone 3 (p = 0.056). Ten years survival and freedom from aortic related mortality were 55 and 91%, respectively. Freedom from descending aorta reintervention was 69% and significantly less in CAD (49%) and AA (64%) compared with AAD (85%) patients (p = 0.001).

Conclusion: FET is a safe procedure for each kind of multisegmental thoracic aortic disease. Less operative consuming time for aortic arch repair may improve the results. Due to the satisfactory durability of the treatment in descending aorta, FET can be considered as the treatment of choice in selected AAD patients. In CAD and extended AA, placement of FET in mid-descending aorta facilitates an additional intervention downstream.