Clinical Research
Combined Frozen Elephant Trunk and Endovascular Repair for Extensive Thoracic Aortic Aneurysms

Presented in part at the 2013 EACTS Techno-College, Vienna, Austria.
https://doi.org/10.1016/j.avsg.2014.12.023Get rights and content

Background

We describe a 1-step treatment of extensive arch and descending aortic aneurysm by combination of frozen elephant trunk (FET) (hybrid endoprosthesis) and of conventional endoprosthesis deployment.

Methods

In a single-center, prospective, treatment-only study, the clinical data of 4 patients receiving combined FET and distal endoprosthesis deployment in the descending aorta were prospectively collected. Thoracic endoprostheses were deployed either retrogradely (off-pump from the femoral arterial access) or antegradely (from the aortic arch during hypothermic arrest). A distal-first approach was used (“trombone” mechanism). Spinal cord protection was achieved by transposition of the left subclavian artery to the left common carotid artery and selective antegrade cerebral perfusion. Preoperative computed tomography scan was performed to identify the collateral circulation. Preoperative planning was assisted by a sizing software (Endosize, Therenva Inc.).

Results

The aortic coverage was extended down to the orifice of the celiac trunk in one case and to the T8 level in the remainders. There was no operative mortality, 1 transient paraparesis, and 1 case of renal insufficiency. Follow-up results were satisfying (no device migration, no endoleak, no endotension, and no late neurologic complications).

Conclusions

The present strategy may abolish the risks connected with the waiting time between the surgical first step and the later completion (aortic-related adverse events and drop-out) and deserves further investigations to determine its safety and feasibility profile.

Introduction

The use of the hybrid endoprosthesis and the frozen elephant trunk (FET) procedure is reliable for the single-stage treatment of thoracic aortic disease extending to the descending segment.1 Although its efficacy in avoiding second-stage surgery is most documented in the setting of acute and chronic dissection, still a second-stage endovascular or surgical completion may be needed after FET whenever the distal extension of aortic pathology exceeds the length of the stent graft portion of the hybrid endoprosthesis.2 This may be required in a proportion of cases which is still scarcely understood, but most frequently in the instance of aneurysm of the entire descending aorta. The waiting time between the FET procedure and the endovascular completion is associated with an incidence of aortic-related adverse events and mortality.1, 3 Thus, the achievement within one procedure of complete repair of extensive arch and descending aortic aneurysm could be advisable in selected cases.

The aim of the present article was to describe a combined endovascular therapy and surgical placement of hybrid endoprosthesis to the purpose of achieving single-stage repair of extensive aortic disease.

Section snippets

Materials and Methods

We prospectively evaluated 4 male patients who received a 1-step treatment for extensive thoracic aortic degenerative aneurysm (Fig. 1) through combined use of FET and endovascular therapy for the descending thoracic aorta. Surgical indications were established in compliance with the current recommendation.4 Preoperative evaluation included contrast-enhanced computed tomography (CT) scan with evaluation of the polygon of Willis (for the assessment of anatomic completeness) and of the

Antegrade Approach: Patient 1

Because of the larger distal extension of the aneurysm in the present case, 2 distal endoprostheses were required (Fig. 1A). Two introducers were positioned percutaneously in the left common femoral artery. An extra-stiff Backup-Meier guidewire (Boston Scientific Inc., Natick, MA) was advanced into the distal aortic arch through the left femoral artery. The celiac trunk was then catheterized with a flexible guidewire (Terumo Inc., Somerset, NJ), serving as distal endovascular landmark to

Discussion

The follow-up results of the FET strategy are encouraging in the setting of acute or chronic aortic dissection. Conversely, it has been pointed out that in event of extensive degenerative aneurysm of the descending aorta, no aneurysmal sack shrinkage is observed at the follow-up in most (63.1%) of the patients treated with the FET procedure alone (including a 15.8% rate of increased distal aortic diameter).1 This could be ascribed to the limitations of the FET technique itself, which may

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This work has been conducted in the experimental platform TherA-Image (Rennes, France) supported by Europe FEDER.

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