Ann Thorac Surg 2009;88:349. doi:10.1016/j.athoracsur.2009.01.007
© 2009 The Society of Thoracic Surgeons
Correspondence
Long-Term Follow-Up of the Frozen Elephant Trunk Technique for Distal Aortic Arch Aneurysm
Akihiko Usui, MD, PhD,
Yuichi Ueda, MD
Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya, 466-8550 Japan
(Email: ausui{at}med.nagoya-u.ac.jp).
To the Editor:
The frozen elephant trunk technique is an alternate modality for synthetic graft replacement of distal arch aneurysms. We have performed the frozen elephant trunk technique for relatively high operative risk patients since 1997. We previously reported the early surgical outcomes of 24 cases in 2002 [1]. However, the long-term follow-up results remain a major concern. We herein report the late results of the same cohort.
There were 24 patients whose cases we followed-up on for more than 7 years, with an average follow-up period of 85 months (range, 3 to 139 months). The patients consisted of 22 males and 2 females, with an average age of 71 years (range, 59 to 83 years). The cases included 22 true aneurysms, 1 chronic dissection, and 1 penetrating aortic ulcer. The stent graft was made with a hand-made "Z" stent and an ultra-thin woven Dacron graft (Ubekosan, Ube, Japan), which were sutured together only at the distal end.
Vascular events related to the frozen elephant trunk technique occurred in 11 cases. Distal site endoleakage was observed in 7 patients, proximal endoleakage in 3, and graft perforation in 1. Distal endoleakage occurred due to stent dislocation in 5 patients and aneurysm formation in 2. Redo surgery for distal endoleakage was performed through a left thoracotomy in 4 patients at 2, 3, 4, and 6 years after surgery, respectively. In addition, 3 other patients died due to an aortic rupture in 2 and chronic obstructive pulmonary disease in 1. Redo surgery was also required for proximal endoleakage in 3 cases through a median-sternotomy at 1, 3, and 9 years after surgery. A graft perforation occurred due to stent penetration from graft kinking, and an emergency operation was required at 6 years after surgery. The vascular event-free rate was 76.9 ± 9.1% at 5 years and 25.2 ± 18.9% at 10 years after surgery.
There were 9 late deaths, including an aortic rupture in 2 patients. The survival rate was 68.6 ± 10.0% at 5 years and 41.9 ± 14.0% at 10 years after surgery. The major cause of vascular events was stent dislocation.
When the graft is implanted into the distal arch, the center of the graft is retracted by the blood flow, thus resulting in graft kinking. The stent thereafter migrates cranially, according to graft kinking and distal site endoleakage (type Ib), which thereafter eventually occurs. We therefore applied some anchoring sutures to fix the graft to the native aorta in the last 11 patients. As a result, no stent migration was observed in this series; however, aneurysmal formation occurred in 2 cases (type V). Anchoring sutures may improve the late results; otherwise, a full stented graft should be used to effectively prevent a graft kinking. Our late results are worse than those of the other reports [2, 3]. This phenomenon may be related to either the materials or the design of the stent graft. An improvement in the stent design should contribute to improved late outcomes. Vascular events still occurred several years after surgery; therefore, a careful periodical follow-up is important to detect any vascular events.
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References
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- Usui A, Fujimoto K, Ishiguchi T, Yoshikawa M, Akita T, Ueda Y. Cerebrospinal dysfunction after endovascular stent-grafting via median-sternotomy (frozen elephant trunk procedure) Ann Thorac Surg 2002;74:S1821-S1824.[Abstract/Free Full Text]
- Pichlmaier MA, Teebken OE, Khaladj N, Weidemann J, Galanski M, Haverich A. Distal aortic surgery following arch replacement with a frozen elephant trunk Eur J Cardiothorac Surg 2008;34:600-604.[Abstract/Free Full Text]
- Uchida N, Ishihara H, Shibamura H, Kyo Y, Ozawa M. Midterm results of extensive primary repair of the thoracic aorta by means of total arch replacement with open stent graft placement for an acute type A aortic dissection J Thorac Cardiovasc Surg 2006;131:862-867.[Abstract/Free Full Text]
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