Management of Thoracoabdominal and Abdominal Aortic Pathology Following Frozen Elephant Trunk Repair

Hybrid endovascular frozen elephant trunk (FET) devices effectively treat proximal aortic disease alone or with staged thoracoabdominal aorticaneurysm (TAAA) repair. Our review assessed post-FET occurrences of distal TAAA or abdominal aortic aneurysm (AAA) pathology, interventions performed, and early/mid-term outcomes. We performed a single-center retrospective review of all patients who underwent total aortic arch replacement with a FET between November 2014 and October 2023. Primary aims were to identify: (1) the incidence of distal aortic pathology requiring reintervention, (2) type of intervention performed, and (3) major adverse outcomes (mortality, cardiac events, stroke, renal failure, and spinal cord ischemia). Ninety-four patients underwent treatment with FET for aortic aneurysms (n = 90; 96%), dissections (n = 49; 52%) or a combination of both (n = 45; 48%) involving the aortic arch. Of these, 36 (38%; 22 males, 61%; mean age 63.6 ± 15.4 years) had TAAAs (26; 72%), AAAs (7; 19%), and type B dissection (3; 8%). Average follow up was 2.5 ± 2.2 years. Connective tissue disorders were diagnosed in five patients (14%). Twenty-two patients (61%) had a carotid-subclavian bypass prior to FET. Nineteen patients (53%) required intervention beyond arch repair: 16 (44%) completed, two pending, and one death prior to second stage with multiorgan failure post-FET. Among the 16 patients, 10 (63%) had open (n = 3) or hybrid (n = 7) repair, and six (38%) had endovascular treatment. Staged open repair, used to minimize spinal cord and visceral ischemia, included one-stage (n = 5; 50%, with two patients undergoing hybrid repair), two-stage (n = 3; 30%), three-stage (n = 1; 10%), and four-stage (n = 1; 10%) procedures for TAA repair across 10 patients. Twelve patients required a spinal drain with no complications. In-hospital mortality was observed in one of 16 patients (6%), stroke in one of 16 (6%), sepsis in two of 16 (13%; line sepsis), and bowel ischemia in two of 16 (13%) requiring bowel resection. None suffered permanent paraplegia or required dialysis. Two patients (13%) died during follow-up: one from cardiac arrest at 1-year post hybrid repair, and the second from a ruptured AAA 9 days after stage one of two TAA repair. Endoleaks were identified in four patients (27%), with three requiring reintervention. Nearly 40% of patients undergoing FET have distal aortic disease potentially requiring planned intervention. FET followed by open, hybrid, or endovascular repair for TAA or arch-involved dissections yield acceptable morbidity and mortality despite extensive aortic involvement. Although staged procedures require more time and resources, staging may reduce the risks of spinal cord and visceral ischemia.