The frozen elephant trunk technique: impact of proximalization and the four-sites perfusion technique

• Published in: European journal of cardio-thoracic surgery Vol. 61; no. 1; pp. 195 - 203
• Main Authors: Tsagakis, Konstantinos, Osswald, Anja, Weymann, Alexander, Demircioglu, Aydin, Schmack, Bastian, Wendt, Daniel, Jakob, Heinz, Ruhparwar, Arjang
• Format: Journal Article
• Language: English
• Published: Germany Oxford University Press 27.12.2021
• Subjects: Aneurysm, Dissecting - surgery; Aorta, Thoracic - surgery; Aortic Aneurysm, Thoracic - surgery; Blood Vessel Prosthesis Implantation - methods; General Adult Cardiac; Humans; Perfusion; Retrospective Studies; Treatment Outcome; Organ protection; Frozen elephant trunk; Aortic surgery; Perfusion
• ISSN: 1010-7940; 1873-734X; 1873-734X
• DOI: 10.1093/ejcts/ezab295

Abstract   OBJECTIVES To improve organ protection with the frozen elephant trunk (FET) procedure, a so-called four-sites perfusion in combination with proximalization for the distal aortic anastomosis was performed. The impact of these techniques on patient outcome is reported. METHODS Between February 2005 and April 2020, a total of 357 patients underwent the FET procedure for acute (54%) or chronic (22%) aortic dissection or aneurysmal disease (24%). The level of the distal FET anastomosis was defined according to aortic arch zones 0–3. Patients were divided into 3 groups according to the intraoperative perfusion strategy: (i) selective antegrade cerebral perfusion (SACP) alone (N = 96, 2 sites); (ii) SACP plus left subclavian artery or distal aorta (N = 84, 3 sites) and (iii) SACP plus left subclavian artery plus distal aorta (N = 177, 4 sites). Early outcome was addressed by a composite end point: occurrence of either a disabling stroke, a disabling spinal cord injury, extracorporeal circulatory support, kidney dialysis or death within 90 days. RESULTS Preoperative characteristics were similar among the groups. Surgery in group C was characterized by FET proximalization in arch zone ≤2, moderate hypothermia at 28°C and shorter periods of extracorporeal circulation, SACP, hypothermic circulatory arrest and cardioplegic arrest (P < 0.001, respectively). Occurrence of the composite end point was reduced in group C (P = 0.008). The combination of FET proximalization and four-sites perfusion was a protective factor for the composite outcome in multivariable analysis (P = 0.009). The 5-year survival was improved in patients who underwent FET proximalization in zone ≤2 (hazard ratio 0.7, 95% confidence interval 0.4–1.0; P = 0.036). CONCLUSIONS FET proximalization in combination with four-sites perfusion has the potential to improve patient outcomes in terms of survival and major events. Subject collection 120; 161. The frozen elephant trunk (FET) procedure is a major operation with substantial risks of morbidity and mortality [1–3].