Aortic remodeling, distal stent-graft induced new entry and endoleak
following frozen elephant trunk: A systematic review and meta-analysis
Abstract
Background: The introduction of the frozen elephant trunk (FET)
technique for total arch replacement (TAR) has revolutionized the field
of aortovascular surgery. However, although FET yields excellent
results, the risk of certain complications requiring secondary
intervention remains present, negating its one-step hybrid advantage
over conventional techniques. This systematic review and meta-analysis
sought to evaluate controversies regarding the incidence of FET-related
complications, with a focus on aortic remodeling, distal stent-graft
induced new entry (dSINE) and endoleak, in patients with type A aortic
dissection (TAAD) and/or thoracic aortic aneurysm. Materials and
methods: A comprehensive literature search was conducted using multiple
electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to
identify evidence on TAR with FET in patients with TAAD and/or aneurysm.
Studies published up until January 2022 were included, and after
applying exclusion criteria, a total of 43 studies were extracted.
Results: A total of 5068 patients who underwent FET procedure
were included. The pooled estimates of dSINE and endoleak were 2% (95%
CI 0.01-0.06, I 2 = 78%) and 3% (95% CI 0.01-0.11,
I 2 = 89%), respectively. The pooled rate of
secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7%
(95% CI 0.05-0.12, I 2 = 89%) whilst the pooled rate
of false lumen thrombosis at the level of stent-graft was 91% (95% CI
0.75-0.97, I 2 = 92%). After subgroup analysis,
heterogeneity for dSINE and endoleak resolved among European patients,
where Thoraflex Hybrid and E-Vita stent-grafts were used (both I
2 = 0%). In addition, heterogeneity for secondary
TEVAR after FET resolved among Asians receiving Cronus (I
2 = 15.1%) and Frozenix stent
-grafts (I 2 = 1%).
Conclusion: Our results showed that the FET procedure in
patients with TAAD and/or aneurysm is associated with excellent results,
with a particularly low incidence of dSINE and endoleak as well as
highly favorable aortic remodeling. However the type of stent-graft and
the study location were sources of heterogeneity, emphasizing the need
for multicenter studies directly comparing FET grafts. Finally,
Thoraflex Hybrid can be considered the primary FET device choice due to
its superior results.