Annals of cardiothoracic surgery最新文献

The frozen elephant trunk (FET) technique has become a cornerstone in the management of complex aortic arch disease, yet reinterventions, both proximally on the root and distally on the thoracoabdominal aorta, remain common. Conventional FET prostheses were designed to recreate standard arch anatomy with the distal anastomosis beyond the left subclavian artery (LSA) and the supra-aortic branches in proximal-to-distal sequence. However, the current trend towards more proximal anastomosis in zones 0-2, brings the arch branches closer to the aortic root, which can limit root access during reoperation by reducing the available clamping zone, and also creates unfavorable angulations for antegrade visceral vessel cannulation during distal endovascular repair. Here, we describe the step-by-step operative technique for a new graft, the T-NEXT, a customized modification of the Thoraflex hybrid prosthesis, designed for improved life-time management of complex aortic disease, featuring a transverse and distal alignment of the arch branches. This configuration leaves an unobstructed proximal graft segment to facilitate safe distal clamping in future proximal reoperations, while preserving a smooth, bidirectional pathway for antegrade and retrograde endovascular access.

Background: The frozen elephant trunk (FET) technique has revolutionized the surgical management of aortic dissection. However, distal stent-graft-induced new entry (dSINE) and reinterventions remain major challenges. This study presents the long-term results of a dissection-specific (DS) "Soft Elephant Trunk" (SET) (MedEng, Penza, Russia) hybrid prosthesis and its impact on distal remodeling compared to conventional hybrid prosthesis.

Methods: A retrospective review of hybrid aortic repairs from 2014 to 2024 identified 241 patients with aortic dissection. Patients were categorized into two cohorts: DS SET prosthesis (n=170) and conventional prosthesis (non-DS, n=71). Propensity score matching was performed. Primary endpoints included the incidence of dSINE and aortic reinterventions. Secondary endpoints evaluated perioperative complications and long-term survival. Cox regression analysis identified independent predictors of dSINE.

Results: Survival rates, freedom from reoperation, and the incidence of dSINE did not differ between the groups. However, cumulative incidence of new events-including distal aortic reoperations and dSINE-was significantly lower in the DS group versus non-DS both before matching (12.9% vs. 29.6%, P<0.001) and after matching (15.5% vs. 29.6%, P=0.04). Long-term endoleak rates (>5 years) were significantly higher in the non-DS group (31.4% vs. 7.1%, P=0.009). According to multivariable Cox regression analysis, the key predictors for dSINE included connective tissue disease [hazard ratio (HR) =3.22, 95% confidence interval (CI): 1.09-9.52, P=0.034], Stanford type B aortic dissection (HR =4.3, 95% CI: 7-14.61, P=0.019), and chronic phase of dissection (HR =7.8, 95% CI: 0.72-84.21, P=0.09). The highest dSINE risk was observed in non-DS patients with chronic dissection (P=0.009), Type B dissection (P=0.012), CTD (P=0.005), and aortic dilation >45 mm (P=0.004).

Conclusions: In comparison to conventional hybrid grafts, the SET graft exhibits a protective trend against dSINE, particularly in high-risk cases. This strategy may reduce distal complications and the need for secondary interventions, thereby improving long-term patient outcomes.

The frozen elephant trunk (FET) technique represents a significant advancement in the surgical management of complex aortic pathologies involving the aortic arch and descending thoracic aorta. This review traces the evolution of the FET procedure from its conceptual origins in the conventional elephant trunk (ET) technique to its current application as a hybrid, single-stage intervention. The FET technique integrates open surgical repair with endovascular technology, allowing for simultaneous aortic arch replacement and stent-graft deployment into the descending aorta. Key indications include acute and chronic aortic dissections, arch aneurysms, and malperfusion syndromes. Surgical considerations such as cannulation strategy, cerebral protection, and spinal cord preservation are discussed in detail, with emphasis on techniques that enhance safety and outcomes. The development of commercially available FET prostheses-such as E-vita Open Neo, Thoraflex Hybrid, and Frozenix-has improved procedural versatility and enabled individualized treatment strategies. Innovations in graft design, including proximalization of distal anastomosis and integration of side branches, have further simplified the procedure and broadened its applicability. Despite variability in outcomes across patient populations, the FET procedure is associated with favorable early and mid-term results, including reduced inter-stage mortality and enhanced aortic remodeling. The technique continues to evolve, driven by advances in device technology and a growing emphasis on tailored, patient-specific surgical approaches.

Background: The frozen elephant trunk (FET) provides single-stage repair of complex, concomitant aortic arch and descending aortic disease, integrating both conventional and endovascular approaches. While multiple meta-analyses affirm short-term safety, long-term outcomes remain largely unknown, especially regarding overall survival and freedom from re-intervention. This current systematic review and meta-analysis aims to summarize the short- and long-term outcomes following the use of FET in aortic pathology.

Methods: Studies with at least two years of follow-up data on FETs were identified in five electronic databases, which were searched from inception of records until July 2025. The primary outcome of interest was mortality, with short-term data presented as either 30-day or in-hospital mortality, and long-term data as aggregated Kaplan-Meier curves. Subgroup analysis was also compared by etiology. Secondary outcomes included relevant morbidity outcomes.

Results: Following independent screening, 28 studies were included for analysis, with 11,292 patients and a mean follow-up period of 40.4 months. Actuarial overall survival at 1, 5 and 10 years was 86.2%, 78.8% and 67.9%, respectively. Long-term survival for acute dissection for these points was marginally higher, at 86.2%, 82.4%, and 75.2%, respectively. Overall freedom from distal reintervention at 1, 5, and 10 years was 93.9%, 87.4% and 81.5%, respectively. Comparatively, pooled short-term mortality was marginally higher in the aortic dissection cohort than the overall cohort at 7.7% [95% confidence interval (CI): 6-11%] and 7% (95% CI: 5-9%), respectively. The breakdown for these was 254/3,379 and 742/9,428 patients, respectively. For the overall cohort, postoperative spinal cord injury (SCI), postoperative cerebrovascular accident (CVA), and acute renal failure (ARF) requiring dialysis were 4%, 8% and 11%, respectively. Pooled mean intensive care unit (ICU) length of stay was 7 days. A high level of heterogeneity was present, likely due to the mixed etiologies included.

Conclusions: Our long-term data expands on previous literature while affirming similar favorable long-term survival for the FET procedure. The consistent pattern of improved late-survival in acute dissections supports the hypothesis that early false-lumen exclusion and acute remodeling result in clear long-term benefits. The need for re-intervention has remained consistent with the published literature, further highlighting the importance of patient selection.

Background: Marfan syndrome (MFS) is a connective tissue disease which can lead to aortic aneurysm and dissection. The performance outcomes of total aortic arch replacement with frozen elephant trunk (FET) are not well known in these patients. This study summarizes our experience with FET in MFS.

Methods: Between August 2001 and December 2021, 435 patients underwent FET at Hannover Medical School. Of these, 34 patients had MFS. The mean age was 43.3±11.9 years and 27 (79%) were male. The indication for surgery was aortic aneurysm in 1 (3%), acute aortic dissection in 12 (35%), and chronic aortic dissection in 21 (62%) patients.

Results: All patients underwent total aortic arch replacement with FET. In addition, the following procedures were performed: conventional aortic root replacement (Bentall operation, n=8), valve-sparing aortic root replacement (David procedure, n=8), coronary artery bypass grafting (n=3), mitral valve surgery (n=2), and tricuspid valve surgery (n=1). Cardiopulmonary bypass (CPB) and aortic cross clamp times were 270±87 and 139±69 minutes, respectively. Postoperatively, there were 2 (6%) disabling strokes, and 0 (0%) patients required permanent dialysis or suffered from permanent paraplegia, respectively. In-hospital mortality was 12% (n=4). The mean follow-up time was 8.4±5.9 years. The 1-, 5-, 10, and 15-year survival rates were 82%, 70%, 70% and 65, respectively. There were 18 (53%) re-interventions on the distal aorta. Mean time to re-intervention was 2.7±3.1 years. The majority of patients underwent open surgical repair (n=14, 77%), while only 4 (22%) had endovascular therapy. The freedom from distal aortic re-intervention at 1-, 5-, 10- and 15 years was 86%, 61%, 55% and 44%, respectively.

Conclusions: The main indication for FET surgery in MFS is acute or chronic aortic dissection. Despite multiple concomitant procedures, early mortality was relatively low, suggesting that FET is feasible and effective to treat complex aortic pathology in MFS. However, our study showed a high incidence of distal aortic re-interventions, underscoring the progressive nature of the disease and the need for tailored long-term management strategies.

Background: The frozen elephant trunk (fET) has become the preeminent choice for aortic arch repair with easier second-stage endovascular solutions compared to the conventional elephant trunk (cET). Traditionally, the major advantage of cET implantation is reduced risk of spinal cord injury (SCI). With increased rates of implantation and refinement in technique, we aim to investigate if previous adverse events of fET, such as SCI, have been reduced to a level comparable to the cET.

Methods: Four databases were searched from inception to January 2025. All studies reporting 30-day mortality and SCI in conventional or fETs were identified. Papers that included emergency surgery in a mixed cohort or novel and handmade prosthesis were excluded. Relevant data was extracted, and meta-analysis was conducted using a random effects model.

Results: Twenty-eight studies were included with a total of 1,504 patients (122 cET, 1,382 fET). Cohort sizes ranged from 12 to 126 patients. The aggregate mean age was 60.7 years for fET and 65.6 years for cET. The 30-day mortality was 5.4% for fET and 3.9% for cET. There was a signal towards increased SCI for fET at 4.4% compared to 1.2% in cET.

Conclusions: In non-emergent total arch replacement, there were similar rates of 30-day mortality. There was a signal towards increased SCI for fETs compared to cETs. Meta-regression identified a non-significant trend towards decreasing rates of SCI in fETs over time.