The frozen elephant trunk treatment is the operation of choice for all kinds of arch disease

Abstract

Background: Frozen elephant trunk (FET) is considered to be the treatment of choice in complex multi-segmental thoracic aortic disease involving the distal arch. Institutional results of FET technique are presented.

Methods: From January 2005 to October 2017, 286 patients underwent FET surgery in our department. Patients (mean age 59±11 years) were operated for acute type I (55%) aortic dissection (AD), chronic AD (23%) and aneurysm (22%). Arch repair was performed with the E-vita Open prosthesis under with selective cerebral perfusion and hypothermic circulatory arrest. Zone 2 arch repair was applied in combination with debranching of the left subclavian artery. Redo-surgery after previous sternotomy underwent 52 patients.

Results: Distal FET was moved from Zone 3 (36%) to Zone 2 (64%) during the past 10 years. Thirty-day mortality was 11% and similar in patients after first or redo-sternotomy (P=1.000). Proximalization of the anastomosis in Zone 2 improved permanent cerebral (4% vs. 8%, P=0.285) as wells as spinal events (2% vs. 4%, P=0.256) though not yet statistically significant. However, postoperative renal (26% vs. 43%, P=0.004) and pulmonary failure (19% vs. 42%, P<0.001) could be decreased significantly. Five-year survival was 75% and also improved with Zone 2 arch repair (P=0.022). Distal aortic arch pathology was excluded in all but one patient. Freedom from re-intervention downstream was 81% and was improved in acute AD compared to chronic AD and aneurysm (P=0.001). Not a single endoleak type I was encountered with this surgical-endovascular approach.

Conclusions: FET is the surgical treatment option of choice to achieve lasting results down to the stent-graft end for all comers with all kinds of arch disease and facilitates additional endovascular or surgical treatment downstream, if required. FET in combination with debranching enabling Zone 2 arch repair improved the results. However, FET remains major surgery and less invasive techniques including complete endovascular arch repair methods are welcome to increase our treatment armamentarium especially in frail multi-morbid patients.