Modified and "reverse" frozen elephant trunk repairs for extensive disease and complications after stent grafting

The frozen elephant trunk (FET) repair technique combines conventional arch repair with the patient under circulatory arrest with stent grafting and is increasingly being used to treat extensive thoracic aortic disease. This surgical approach is evolving, including its use for complications after thoracic aortic stent grafting - the so-called reversed frozen elephant trunk (RFET). We evaluated the safety and efficacy of FET and RFET operations in high-risk patients.

Between July 2001 and December 2010, 31 patients underwent FET and 19 patients underwent RFET for extensive thoracic aortic disease. Causes included aneurysm (n=32), acute dissection (n=17), and rupture (n=1). Twenty-three cases (46%) were for urgent or emergency indications. Patient data and outcomes were collected through a prospectively maintained clinical database and 3-dimensional analysis of computed tomography (CT) scans. Outcomes were assessed using Kaplan-Meier methodology.

In-hospital mortality was 8% (n=4, including 1 emergency RFET procedure for aortic rupture and 2 urgent FET procedures for symptomatic degenerative aneurysm). Stroke occurred in 5 patients (10%) and spinal cord injury in 4 patients (8%). Mean hospital stay was 14.3 days (range 4 to 67 days). Five endoleaks were observed (4 type II, 1 type I) requiring 2 endovascular reinterventions. Mean follow-up was 17 months (range, 1 to 76 months) and actuarial survival was 87% at 2 years.

Frozen elephant trunk repair is an effective surgical strategy for managing high-risk patients with extensive pathologic conditions of the thoracic aorta. The RFET approach is a feasible option for proximal aortic complications after previous descending stent grafting. Intermediate outcomes are reasonable for both approaches and further evaluation of these techniques is warranted.