Stent graft kinking after total arch replacement using frozen elephant trunk with E-Vita open Neo

Postoperative kinking of a stent graft following total arch replacement using a frozen elephant trunk technique (TARFET) is a rare but significant complication. Such kinking can lead to serious issues, including heart failure, hemolysis, graft thrombosis, and significant upper and lower limb blood pressure difference. Although several cases involving various frozen elephant trunk (FET) devices have been documented, this report presents a potentially novel instance of stent graft kinking following implantation of an E-Vita Open Neo prosthesis.

A 48-year-old female with a complex cardiac history including previous coarctation repair, aortic valve replacement (AVR), and aortic root enlargement presented with mild hemoptysis, chest, and back pain. Imaging test revealed a growing aortic aneurysm (5.5 cm) at the anastomosis site, severe aortic arch angulation (55°), and prosthesis-patient mismatch with mitral regurgitation. She underwent total arch replacement with the frozen elephant trunk technique and double valve replacement. Postoperatively, she developed stent graft kinking and a significant systolic pressure gradient between upper and lower extremities, along with microangiopathic hemolytic anemia (MAHA) and elevated lactate dehydrogenase (LDH). Balloon dilatation and stent graft relining reduced the pressure gradient from 80 mmHg to 20 mmHg and resolved her symptoms. Follow-up computed tomography angiography (CTA) showed slight improvement in arch lumen size, while microangiopathic hemolytic anemia and lactate dehydrogenase levels normalized.

Stent graft kinking after total arch replacement with the frozen elephant trunk technique is a rare but potentially severe complication requiring prompt intervention when symptomatic. In the present case, the kinking was likely due to severe aortic arch angulation and fibrotic changes from prior surgeries. To reduce the risk of kinking in patients with significant aortic arch angulation, conventional total arch replacement or performing the distal anastomosis beyond the angulation should be considered during total arch replacement with the frozen elephant trunk procedure.