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Combined open and endovascular treatment for extensive aortic diseases using the frozen elephant trunk technique: early mortality is mainly influenced by the underlying pathology
Christian Detter, Jens Brickwedel, Marcel Coutandin, Thilo Koelbel, Hermann Reichenspurner.
University Heart Center Hamburg, Hamburg, Germany.

OBJECTIVE: The frozen elephant trunk (FET) procedure is a technique for combined, single-stage open and endovascular treatment of patients with extensive diseases of the thoracic aorta. Despite modern cerebral perfusion techniques, morbidity and mortality remains high. This study aims to evaluate early mortality using FET technique according to the underlying pathology.
METHODS: Between July 2011 and December 2015, a total of 56 consecutive patients (mean age 65.1 ± 10.7 years) underwent FET surgery using moderate circulatory arrest (CA) and selective antegrade cerebral perfusion (SACP). Underlying pathologies were complex thoracic aneurysm in 19 (33.9%) patients, acute aortic dissection in 21 (37.5%), and chronic dissection in 16 (28.6%) patients. Six (10.7%) patients suffered from acute aortic rupture, 23 (41.1%) patients underwent emergency procedures, and 13 (23.2%) patients had a redo operation. Connective tissue disease was genetically diagnosed in 6 (10.7%) patients.
RESULTS: Cardiopulmonary bypass, X-clamp, CA, and SACP times were 248.0 ± 54.6 min, 151.6 ± 66.3 min, 78.0 ±38.0 min, and 86.0 ±41.0 min, respectively. Overall 30-day mortality rate was 16.1% (n=9 patients). In patients who underwent emergency operation, 30-day mortality was 30.4% (7/23 patients). Of these, 5 patients suffered from acute aortic rupture and were referred in critical preoperative status. In patients who underwent elective operation, early mortality (2/31 patients) was significantly lower compared to emergency cases (6.0% vs. 30.4%, p<0.03). Both patients died as a result of multiple embolization due to severe arteriosclerosis. None of the redo patients and patients with connective tissue disease died. New postoperative strokes were observed in 6 (10.7%) patients and spinal cord injury in 1 (1.8%) patient.
CONCLUSIONS: The FET technique remains a challenging surgical technique. However, early mortality is mainly influenced by the underlying pathology than by the technique itself. In elective cases, connective tissue disease, and redo operations, FET can be performed with good early results in experienced centers.

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