Aortic Reinterventions after Frozen Elephant Trunk Surgery: An Underestimated Risk

Objectives: This study analyses the frequency of reinterventions after frozen elephant trunk surgery (FET) in a 10-year single-center patient cohort.

Methods: From 10/2010 to 04/2020, we performed 140 FET procedures at our center (59.3% male, age 62.3 ± 13.7, EuroSCORE II: 14.7 ± 12.7%). Underlying pathologies were thoracoabdominal aneurysms (TAA) in 39.2%, chronic type A or type B aortic dissections (CAD) in 30.7%, and acute aortic syndromes (AAS) in 29.9% of cases. Mean follow-up was 18.2 ± 22.5 months and included CT or MRI imaging postoperatively or at 3 months, 12 months, and thereafter depending on aortic pathology. The indication for reintervention was consented in an interdisciplinary aortic case conference.

Result: Procedural survival of the initial FET surgery was 98.6%. Overall 30-day survival was 87.9%. Postoperative serial imaging detected relevant progression of the aortic pathology in 41.5% (n = 51), leading to aortic reinterventions during follow-up (n = 12 at 30 days; n = 46 at 2 years; n = 51 at 5 years). Reinterventions were endovascular (TEVAR/EVAR/fenestration of dissection membrane) in 92.2% (n = 47). Complete thoracoabdominal repair (Crawford procedure) was performed in 7.8% (n = 4), all suffering from connective tissue disorder.

Indications for reintervention were treatment for residual dissection, remaining TAA, and postoperative malperfusion syndromes in 54.9, 39.2, and 5.9%, respectively. In patients receiving aortic reintervention for remaining TAA and residual dissections, Endoleak type Ib was found in 95 and 64% of patients, respectively. Rates of freedom from reintervention 5 years after FET procedure for TAA, CAD, and AAS were 21.0, 22.7, and 49.0%, respectively, as shown in Kaplan–Meier analysis. In patients suffering from AAS, the rate of aortic reintervention was significantly lower than in patients suffering from TAA and CAD (p = 0.004). Aneurysms in the descending aorta with a diameter of >1 cm above the FET stent diameter was associated with higher rates of reinterventions (p = 0.032). Genetic aortic syndrome was not statistically significant associated with the need for reintervention.

The 1-year survival rate after reintervention was 90.2%.

Conclusion: Due to the extensive aortic disease in this FET patient cohort secondary interventions after initial FET procedure are frequently required to complete the aortic repair. 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.

Publication History

Article published online:
19 February 2021