Aortic Proximalisation -- Zone 0 vs. Zone 2. A Concept or True
Challenge?
Abstract
Background Use of the Frozen Elephant Trunk (FET) device to manage
complex surgical pathologies of the aorta (e.g. acute Type A aortic
dissection) has gained popularity since its introduction in the early
2000s. Though the distal anastomosis was traditionally performed at Zone
3 (Z-3-FET), preference gradually shifted towards Zone 2 (Z-2-FET) in
favour of improved surgical access and outcomes. This review seeks to
elucidate whether proximalisation of arch repair to Zone 0 (Z-0-FET)
would further improve postoperative outcomes. Methods We performed a
review of available literature to evaluate the comparative efficacies of
Z-2-FET versus Z-0-FET, in terms of surgical technique, clinical
outcomes, and incidence of adverse events. Results Z-0-FET seems to be
associated with a more accessible surgical approach, and shorter
cardiopulmonary bypass, antegrade cerebral perfusion, and cardioplegia
durations than Z-2-FET. Further, Z-0-FET is could potentially be
associated with a lower incidence of neurological, renal, and recurrent
laryngeal nerve injury, as well as mortality and reintervention rates
than Z-2-FET. This said, Z-0-FET is itself associated with significant
challenges, and efficacy in terms of postoperative true lumen integrity
and false lumen thrombosis is mixed. Conclusion Current literature seems
to suggest that Z-0-FET procedures are more straightforward and
associated with lower rates of certain adverse events, however, the
majority of data reviewed is retrospective. This review therefore
recommends prospective research into the comparative strengths and
limitations of Z-0-FET and Z-2-FET to better substantiate whether
proximalisation of arch repair represents a concept, or a true challenge
to advance surgical intervention for arch pathologies.