Incidence, Risk Factors, and Clinical Impact of Intra-Stent Graft Thrombosis in the Thoracic Aorta

Abstract

Objectives: Stentgrafts in the thoracic aorta, whether placed during the frozen elephant trunk procedure or thoracic endovascular repair, have been associated with thrombosis. This study aimed to evaluate its incidence, risk factors, and clinical consequences.

Methods: PubMed, Web of Science, and SCOPUS were systematically searched for relevant studies. Quality assessment was performed using the Risk of Bias in Non-Randomized Studies of Interventions tool for cohort studies and the Joanna Briggs Institute checklist for case reports. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Results: Seventeen studies were included: 4 cohort studies (825 patients) and 3 case reports on frozen elephant trunk, 3 cohort studies (142 patients), and 12 case reports on thoracic endovascular repair. The pooled incidence of intra-stent graft thrombosis after frozen elephant trunk was 8.6% (95% CI: 5.7-12.9), typically occurring within 1 week and significantly associated with older age, female sex, aneurysmal disease, and higher rates of dialysis (43% vs 16%) and mortality (25% vs 8%). Thoracic endovascular repair cohorts were heterogeneous and could not be pooled; therefore, findings were synthesized narratively. One trauma cohort reported an incidence of 20.6%. All 12 case reports involved patients treated for trauma, with a mean time to diagnosis of 12 ± 6.3 months; 8 presented with spinal cord injury; 11 underwent an intervention to address the thrombosis.

Conclusions: Intra-stent graft thrombosis is relatively common after frozen elephant trunk and may be underrecognized after thoracic endovascular repair, particularly in trauma patients. Structured imaging follow-up and individualized treatment strategies are warranted.

Keywords: frozen elephant trunk; intra-luminal thrombosis; intra-stent graft thrombosis; spinal cord injury; stent; thoracic endovascular aortic repair; thrombosis; trauma.