Modified and "Reverse" Frozen Elephant Trunk Repairs for Extensive Disease and Complications After Stent Grafting
Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio 44195-5108, USA. The Annals of thoracic surgery
(Impact Factor: 3.85).
11/2011; 93(1):103-9; discussion 109. DOI: 10.1016/j.athoracsur.2011.08.034
The frozen elephant trunk (FET) repair technique combines conventional arch repair with the patient under circulatory arrest with stent grafting and is increasingly being used to treat extensive thoracic aortic disease. This surgical approach is evolving, including its use for complications after thoracic aortic stent grafting - the so-called reversed frozen elephant trunk (RFET). We evaluated the safety and efficacy of FET and RFET operations in high-risk patients.
Between July 2001 and December 2010, 31 patients underwent FET and 19 patients underwent RFET for extensive thoracic aortic disease. Causes included aneurysm (n=32), acute dissection (n=17), and rupture (n=1). Twenty-three cases (46%) were for urgent or emergency indications. Patient data and outcomes were collected through a prospectively maintained clinical database and 3-dimensional analysis of computed tomography (CT) scans. Outcomes were assessed using Kaplan-Meier methodology.
In-hospital mortality was 8% (n=4, including 1 emergency RFET procedure for aortic rupture and 2 urgent FET procedures for symptomatic degenerative aneurysm). Stroke occurred in 5 patients (10%) and spinal cord injury in 4 patients (8%). Mean hospital stay was 14.3 days (range 4 to 67 days). Five endoleaks were observed (4 type II, 1 type I) requiring 2 endovascular reinterventions. Mean follow-up was 17 months (range, 1 to 76 months) and actuarial survival was 87% at 2 years.
Frozen elephant trunk repair is an effective surgical strategy for managing high-risk patients with extensive pathologic conditions of the thoracic aorta. The RFET approach is a feasible option for proximal aortic complications after previous descending stent grafting. Intermediate outcomes are reasonable for both approaches and further evaluation of these techniques is warranted.
Available from: Adrian V Hernandez
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ABSTRACT: OPINION STATEMENT: Conventional surgery for thoracic aortic pathology involves replacing the affected segment of aorta with an interposition graft and often requires the use of extracorporeal circulatory support with or without deep hypothermic circulatory arrest. Although operative results have improved consistently over 60 years, patients with extensive aneurysms face a considerable risk with conventional surgery, particularly when burdened with multiple comorbidities. Thoracic endovascular aortic repair (TEVAR) was first performed in 1994 and has become a well-established alternative therapy for many thoracic aortic pathologies. TEVAR is most frequently performed through a small groin incision to access the common femoral artery. Wires and catheters are used to deliver and deploy the stent graft in the thoracic aorta under fluoroscopic control. Occasionally, TEVAR is performed as part of a complex hybrid procedure including one stage of conventional open surgery that may utilize a thoracic incision and cardiopulmonary bypass support. The less invasive nature of TEVAR offers the potential for lower mortality and peri-procedural morbidity. Although long-term results of TEVAR are still being gathered, mid-term results are excellent and most late vascular complications can be treated with additional transcatheter procedures. Recent development of fenestrated and branched stent grafts is expanding the application of endovascular therapies to complex aortic pathologies involving the thoracoabdominal aorta and aortic arch. Although conventional techniques continue to be the gold standard for treatment of ascending aortic pathology, recent reports have proven TEVAR to be a viable alternative in specific situations. Design improvements continue to expand the indications for TEVAR, and technological advancements in the field of imaging facilitate safer and more accurate planning, delivery, and assessment of patients with thoracic aortic aneurysms. Hybrid operating rooms provide the optimal environment with state of the art imaging technology for the cardiovascular team to perform TEVAR or alternative hybrid procedures.
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ABSTRACT: Patients with dissecting or aneurysmal disease of the aortic arch represent a unique challenge for the cardiac surgeon, and the employment of valid surgical and endovascular techniques and appropriate methods of cerebral protection is crucial for obtaining satisfactory postoperative results. Open surgical repair remains the approach of choice, even if supported by increasingly improved endovascular procedures. At present, a wide range of surgical, endovascular and hybrid procedures is available for the treatment of these high-risk patients. The aim of this review is to describe the different procedures used in patients with aortic arch pathology and to review the main results available in the literature.
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