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Outcomes And Management Of Distal Aortic Pathologies Following Total Arch Replacement Using A Frozen Elephant Trunk Device: A Single-center Retrospective Review
Apoorva Bhandari, MSc, MD, Michael W.A. Chu, MD, Luc Dubois, MD MSc, Adam Power, MD MPhil, Audra A. Duncan, MD.
Oregon Health & Science University, Portland, OR, USA.
Objectives: Hybrid endovascular frozen elephant trunk (FET) devices are used for proximal aortic disease, either as standalone therapy or as part of a staged thoracoabdominal aortic repair. This study assessed the incidence, management, and early to midterm outcomes of distal aortic pathologies following FET-based arch repair.
Methods: We performed a single-center retrospective review of all patients who underwent total aortic arch replacement with FET between November 2014 and October 2023. Primary outcomes were: (i) incidence of distal aortic pathology requiring further intervention, (ii) intervention type, and (iii) major adverse events including mortality, cardiac events, stroke, renal failure, and spinal cord ischemia.
Results: Ninety-four patients underwent FET treatment for arch aneurysms (90, 96%), dissections (49, 52%) or both (45, 48%). Distal aortic disease occurred in 36 (38%) patients: 26 (72%) thoracoabdominal aortic aneurysms (TAAA), 7 (19%) abdominal aortic aneurysms (AAA), and 3 (8%) Type B dissections. Mean follow-up was 2.5 ± 2.2 years. Five (14%) had connective tissue disorders. Nineteen (53%) required further intervention: 16 (84%) completed, two pending, and one patient died before the second-stage TAAA repair. Of the 16 completed cases, 10 (63%) had open (3, 19%) or hybrid (7, 44%) repair; six (38%) underwent endovascular procedures. Staged open TAAA repair was tailored to minimize spinal cord/visceral ischemia: one-stage (5), two-stage (3), three-stage (1), and four-stage (1). Twelve required spinal drains without complication. Post-intervention complications included in-hospital mortality (1/16, 6%), stroke (1/16, 6%), sepsis (2/16, 13%), and bowel ischemia requiring resection (2/16, 13%). No patients developed permanent paraplegia or required dialysis. Two additional deaths occurred during follow-up: one from cardiac arrest one-year post-hybrid repair, and one from AAA rupture nine days after stage one of a planned two-stage repair. Endoleaks occurred in 4 (27%) patients, with 3 requiring reinterventions.
Conclusions: Distal aortic pathology following FET occurs in nearly 40% of cases, with over half requiring subsequent intervention. Despite the complexity, staged open, hybrid, or endovascular approaches offer acceptable morbidity and mortality. Tailored staging strategies appear effective in reducing spinal cord and visceral ischemia risks.
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