Complicated acute type A aortic dissection and severe aortic atherosclerosis predict early mortality after frozen elephant trunk procedure

Abstract

Objectives: To analyse risk factors for early mortality and long-term survival including secondary distal aortic interventions in patients undergoing frozen elephant trunk surgery.

Methods: A retrospective single-centre study was conducted, including all 222 patients who underwent frozen elephant trunk surgery between 2010 and 2022. We used multivariable regression analysis to detect risk factors for early mortality and Kaplan-Meier analysis for long-term survival and secondary interventions. We introduce the term 'complicated acute type A dissection' for those patients in whom the dissection was complicated by malperfusion syndrome, aortic rupture, pre-hospital intubation or resuscitation.

Results: Thirty-day mortality decreased significantly from 18.9% using the conventional zone 3 technique to 7.4% using a simplified zone 2 technique (P = 0.014). The aortic pathology had a significant impact on 30-day mortality: 1.4% in chronic dissection, 6.7% in aortic aneurysm, 7.4% in noncomplicated acute type A aortic dissection and 42.5% in complicated acute type A aortic dissection (P < 0.001). We identified complicated acute type A aortic dissection [odds ratio 15.7, confidence interval (CI) 5.2-47.3, P < 0.001], severe aortic atherosclerosis (odds ratio 4.9, CI 1.6-15.3, P = 0.006) and impaired renal function (odds ratio 3.7, CI 1.1-12.4, P = 0.035) as independent predictors of early mortality. Among 30-day survivors, 5-year survival was 84.3%, with no differences between pathologies. Secondary distal aortic interventions (37.4%) did not affect 5-year survival (P = 0.909).

Conclusions: Early mortality after frozen elephant trunk surgery is strongly driven by preoperative patient condition, particularly in the presence of complicated acute type A dissection. Once the early postoperative phase is overcome, long-term outcome is favourable across pathologies, regardless of secondary interventions. Careful patient selection and regular follow-up are crucial for optimizing outcomes.

Keywords: Aortic aneurysm; Aortic arch; Frozen elephant trunk; Type A aortic dissection.

Graphical abstract

Figure 1:

Thirty-day mortality by underlying aortic pathology. Thirty-day mortality was 1.4% in chronic dissections and 6.7% in aortic aneurysms. In ATAD, 30-day mortality differed profoundly with 7.4% in uncomplicated ATAD and 42.5% in complicated ATAD.

Figure 2:

Forest plot of the multivariable logistic regression analysis for early mortality. Complicated ATAD (OR 15.70), severe aortic sclerosis (OR 4.89), and impaired renal function (OR 3.69) were identified as independent predictors for 30-day mortality.

Figure 3:

Kaplan–Meier analysis on long-term survival and secondary distal aortic interventions. (A) Long-term survival of the overall cohort. (B) Thirty-day landmark analysis on long-term survival according to the underlying aortic pathology with no statistically significant differences between the groups, Log Rank P = 0.763. (C) Rate of secondary distal aortic interventions according to the underlying aortic pathology with no statistically significant differences between the groups, competing risk analysis, P = 0.509. A: aneurysm; AD: acute dissection; CD: chronic dissection. (D) Thirty-day landmark analysis on long-term survival according to the status of secondary distal aortic intervention with no statistically significant difference between the groups, Log Rank P = 0.909.