Repeat endovascular repair for multiple intimal tears after endovascular stent grafting of Stanford type B aortic dissection

Aortic remodeling, distal stent-graft induced new entry and endoleak following frozen elephant trunk: A systematic review and meta-analysis

BACKGROUND

The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm.

MATERIALS AND METHODS

A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted.

RESULTS

A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% confidence interval [CI] 0.01-0.06, I²  = 78%) and 3% (95% CI 0.01-0.11, I²  = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I²  = 89%) while the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I²  = 92%). After subgroup analysis, heterogeneity for distal stent-graft induced new entry (dSINE) and endoleak resolved among European patients, where Thoraflex Hybrid (THP) and E-Vita stent-grafts were used (both I²  = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I²  = 15.1%) and Frozenix stent-grafts (I²  = 1%).

CONCLUSION

Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, THP can be considered the primary FET device choice due to its superior results.

Endovascular repair of residual intimal tear or distal new entry after frozen elephant trunk for type A aortic dissection

BACKGROUND

In patients with type A dissection, residual dissection and new distal entry tears following the frozen elephant trunk (FET) procedure adversely affect long-term prognosis. Management include open and endovascular repair, while clinical experience is limited. We evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) in management of residual intimal tear or distal new entry tear following FET in patients with type A aortic dissection (TAAD).

METHODS

Between May 2003 and April 2013, we performed FET and total arch replacement for 1,003 patients with TAAD. Among these, 23 patients (2.3%) required TEVAR for distal new entry (n=2) or residual intimal tear (n=21) at a mean of 2.0±1.6 years after FET. Mean age was 50.1±11.5 years. Marfan syndrome was seen in 2 patients (8.7%).

RESULTS

Procedural success was 100%. The distal landing zone was above the 11th thoracic vertebra (T11) in 86.9% (20/23). Neither death nor any paraplegia or stroke occurred early after TEVAR. Follow-up was complete in 100% averaging 2.8±1.7 years (0.3-6.4). One non-Marfan patient died of distal aortic rupture at 4 months after TEVAR. No late stroke or paraplegia occurred. Survival was 95.7% (95% CI, 72.9-99.4%) at 3 and 5 years, respectively. CTA detected false lumen obliteration by thrombus around the endograft in the descending aorta in 91.3% (21/23) of patients.

CONCLUSIONS

These early and midterm outcomes show the efficacy of TEVAR in obliterating the residual intimal tear or distal new entry after FET in patients with TAAD. TEVAR may be an alternative approach to distal new entry or residual intimal tear following FET for patients with TAAD.