TEVAR Following FET: Current Outcomes of Rendezvous Procedures in Clinical PracticeFunding Philipp Geisbüsch has received speaker honoraria and travel grants from WL Gore & Associates, Medtronic, and Abbott. Dittmar Böckler is a consultant for WL Gore & Associates, Siemens AG, and Medtronic and has received educational and research grants, speaker honoraria from WL Gore & Associates, Medtronic, and Siemens. Moritz S. Bischoff has received speaker honoraria from W.L. Gore & Associates. All other authors state that there is no conflict of interest to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Background The treatment of extensive thoracic/thoracoabdominal aortic pathologies with arch involvement remains a challenging task in aortic surgery. The introduction of the frozen elephant trunk (FET) technique offered a link between open surgery and thoracic endovascular aortic repair (TEVAR). Despite a decade of experience, data on the complementary use of these techniques are scant. The aim of this study was to evaluate TEVAR following FET in clinical reality.
Methods Between November 2006 and June 2018, 20 patients (9 females; median age of 69 years) underwent endovascular second-stage completion after FET. The clinical outcomes, technical feasibility, and morphological findings were analyzed retrospectively.
Results Eleven of the 20 interventions were intended “rendezvous procedures” in a multistage approach; 4 were elective reinterventions, and 5 were emergency complication repairs. The median interval between FET and TEVAR was 231 days (11 days–7.4 years). The technical success rate was 100%. During a median follow-up (FU) period of 58.3 months, the overall survival rate was 95%, with one in-hospital death. Neurological complications occurred in three cases (spinal cord injury: n = 1; stroke: n = 2). Computed tomography angiography showed overall regression in the median diameter of the proximal descending aorta (from 57 to 48.5 mm).
Conclusion TEVAR as a second-stage intervention after FET is a feasible option, with satisfactory results at medium-term FU. In extensive thoracoabdominal aortic disease without proximal landing zones, the complementary use of both techniques in a multistage approach should be considered.
Keywordsthoracic endovascular aortic repair - frozen elephant trunk - TEVAR - FET - thoracoabdominal aortic disease - reintervention - outcome
* Both authors contributed equally to this work.
Received: 08 August 2020
Accepted: 07 December 2020
12 February 2021 (online)
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- 1 Karck M, Chavan A, Hagl C, Friedrich H, Galanski M, Haverich A. The frozen elephant trunk technique: a new treatment for thoracic aortic aneurysms. J Thorac Cardiovasc Surg 2003; 125 (06) 1550-1553
- 2 Shrestha M, Martens A, Kaufeld T. et al. Single-centre experience with the frozen elephant trunk technique in 251 patients over 15 years. Eur J Cardiothorac Surg 2017; 52 (05) 858-866
- 3 Kreibich M, Berger T, Rylski B. et al. Aortic reinterventions after the frozen elephant trunk procedure. J Thorac Cardiovasc Surg 2019
- 4 Papakonstantinou NA, Antonopoulos CN, Baikoussis NG, Kakisis I, Geroulakos G. Frozen elephant trunk: an alternative surgical weapon against extensive thoracic aorta disease. a three-year meta-analysis. Heart Lung Circ 2019; 28 (02) 213-222
- 5 Tsagakis K, Jakob H. Which frozen elephant trunk offers the optimal solution? Reflections from Essen Group. Semin Thorac Cardiovasc Surg 2019; 31 (04) 679-685
- 6 Laranjeira Santos Á, Cruz Tomás A, Varela-Afonso D, Pinheiro Santos J, Fragata J. Elective 2nd stage TEVAR to complete frozen elephant trunk in the surgical correction of complex multisegmental pathology of the thoracic aorta. Rev Port Cir Cardiotorac Vasc 2017; 24 (3-4): 164
- 7 Kremer J, Preisner F, Dib B. et al. Aortic arch replacement with frozen elephant trunk technique - a single-center study. J Cardiothorac Surg 2019; 14 (01) 147
- 8 Geisbüsch P, Hoffmann S, Kotelis D, Able T, Hyhlik-Dürr A, Böckler D. Reinterventions during midterm follow-up after endovascular treatment of thoracic aortic disease. J Vasc Surg 2011; 53 (06) 1528-1533
- 9 White GH, Yu W, May J, Chaufour X, Stephen MS. Endoleak as a complication of endoluminal grafting of abdominal aortic aneurysms: classification, incidence, diagnosis, and management. J Endovasc Surg 1997; 4 (02) 152-168
- 10 Fillinger MF, Greenberg RK, McKinsey JF, Chaikof EL. Society for Vascular Surgery Ad Hoc Committee on TEVAR Reporting Standards. Reporting standards for thoracic endovascular aortic repair (TEVAR). J Vasc Surg 2010; 52 (04) 1022-1033 , 1033.e15
- 11 Brunkwall J, Kasprzak P, Verhoeven E. et al; ADSORB Trialists. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodelling: 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg 2014; 48 (03) 285-291
- 12 Nienaber CA, Rousseau H, Eggebrecht H. et al; INSTEAD Trial. Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009; 120 (25) 2519-2528
- 13 Coselli JS, Bozinovski J, LeMaire SA. Open surgical repair of 2286 thoracoabdominal aortic aneurysms. Ann Thorac Surg 2007; 83 (02) S862-S864 , discussion S890–S892
- 14 Pichlmaier MA, Teebken OE, Khaladj N, Weidemann J, Galanski M, Haverich A. Distal aortic surgery following arch replacement with a frozen elephant trunk. Eur J Cardiothorac Surg 2008; 34 (03) 600-604
- 15 Karck M, Chavan A, Khaladj N, Friedrich H, Hagl C, Haverich A. The frozen elephant trunk technique for the treatment of extensive thoracic aortic aneurysms: operative results and follow-up. Eur J Cardiothorac Surg 2005; 28 (02) 286-290 , discussion 290
- 16 Suto Y, Yasuda K, Shiiya N. et al. Stented elephant trunk procedure for an extensive aneurysm involving distal aortic arch and descending aorta. J Thorac Cardiovasc Surg 1996; 112 (05) 1389-1390
- 17 Tian DH, Wan B, Di Eusanio M, Yan TD. Systematic review protocol: the frozen elephant trunk approach in aortic arch surgery. Ann Cardiothorac Surg 2013; 2 (04) 578
- 18 Di Bartolomeo R, Leone A, Di Marco L, Pacini D. When and how to replace the aortic arch for type A dissection. Ann Cardiothorac Surg 2016; 5 (04) 383-388
- 19 Goebel N, Nagib R, Salehi-Gilani S. et al. One-stage hybrid aortic repair using the frozen elephant trunk in acute DeBakey type I aortic dissection. J Thorac Dis 2018; 10 (07) 4195-4203
- 20 Kreibich M, Berger T, Morlock J. et al. The frozen elephant trunk technique for the treatment of acute complicated Type B aortic dissection. Eur J Cardiothorac Surg 2018; 53 (03) 525-530
- 21 Ius F, Fleissner F, Pichlmaier M. et al. Total aortic arch replacement with the frozen elephant trunk technique: 10-year follow-up single-centre experience. Eur J Cardiothorac Surg 2013; 44 (05) 949-957
- 22 Leone A, Beckmann E, Aandreas M. et al. Total aortic arch replacement with frozen elephant trunk technique: results from two European institutes. J Thorac Cardiovasc Surg 2019
- 23 Mestres CA, Tsagakis K, Pacini D. et al; IEOR Registry Group. One-stage repair in complex multisegmental thoracic aneurysmal disease: results of a multicentre study. Eur J Cardiothorac Surg 2013; 44 (05) e325-e331
- 24 Pacini D, Tsagakis K, Jakob H. et al. The frozen elephant trunk for the treatment of chronic dissection of the thoracic aorta: a multicenter experience. Ann Thorac Surg 2011; 92 (05) 1663-1670 , discussion 1670
- 25 Rustum S, Beckmann E, Wilhelmi M. et al. Is the frozen elephant trunk procedure superior to the conventional elephant trunk procedure for completion of the second stage?. Eur J Cardiothorac Surg 2017; 52 (04) 725-732
- 26 Kozlov BN, Panfilov DS, Saushkin VV. et al. Distal aortic remodelling after the standard and the elongated frozen elephant trunk procedure. Interact Cardiovasc Thorac Surg 2019; 29 (01) 117-123
- 27 Meisenbacher K, Geis U, Kauczor HU, Karck M, Boeckler D, Bischoff MS. Discuss many to benefit more - five-year analysis of a multidisciplinary aortic board [in German]. Zentralbl Chir 2020; Mar 23. German. DOI: 10.1055/a-1114-6510.
- 28 Bischoff MS, Scheumann J, Brenner RM. et al. Staged approach prevents spinal cord injury in hybrid surgical-endovascular thoracoabdominal aortic aneurysm repair: an experimental model. Ann Thorac Surg 2011; 92 (01) 138-146 , discussion 146
- 29 Tian DH, Wan B, Di Eusanio M, Black D, Yan TD. A systematic review and meta-analysis on the safety and efficacy of the frozen elephant trunk technique in aortic arch surgery. Ann Cardiothorac Surg 2013; 2 (05) 581-591
- 30 Pan XD, Li B, Ma WG. et al. Endovascular repair of residual intimal tear or distal new entry after frozen elephant trunk for type A aortic dissection. J Thorac Dis 2017; 9 (03) 529-536
- 31 Etz CD, Kari FA, Mueller CS, Brenner RM, Lin HM, Griepp RB. The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrifice. J Thorac Cardiovasc Surg 2011; 141 (04) 1029-1036
- 32 Safi HJ, Miller III CC, Estrera AL. et al. Optimization of aortic arch replacement: two-stage approach. Ann Thorac Surg 2007; 83 (02) S815-S818 , discussion S824–S831
- 33 Schepens MA, Dossche KM, Morshuis WJ, van den Barselaar PJ, Heijmen RH, Vermeulen FE. The elephant trunk technique: operative results in 100 consecutive patients. Eur J Cardiothorac Surg 2002; 21 (02) 276-281
- 34 Etz CD, Plestis KA, Kari FA. et al. Staged repair of thoracic and thoracoabdominal aortic aneurysms using the elephant trunk technique: a consecutive series of 215 first stage and 120 complete repairs. Eur J Cardiothorac Surg 2008; 34 (03) 605-614 , discussion 614–615
- 35 Bischoff MS, Ante M, Meisenbacher K, Böckler D. Outcome of thoracic endovascular aortic repair in patients with thoracic and thoracoabdominal aortic aneurysms. J Vasc Surg 2016; 63 (05) 1170-1181.e1