Does the frozen elephant trunk improve outcome in acute type A aortic dissection with malperfusion?

Purpose: Acute aortic dissection type A (AADTA) has high mortality rate, especially in patients with malperfusion. The frozen elephant trunk (FET) is thought to reduce malperfusion, but so far no study could demonstrate a direct benefit of the FET in this scenario.

Methods: We designed a retrospective study with prospective follow up. We included all patients who underwent surgery for AADTA, and pre-existing malperfusion at our center. We identified a total of 810 patients who underwent surgery for AADTA between 2000 and 2022. Of these, 152 patients had preoperative malperfusion. Patients were assigned to one of two groups depending on the type of surgery: group A (conventional surgery without FET, n=106) or group B (FET surgery, n=46).

Results: The mean age was 64±13 years in group A and 56±12 in group B (p < 0.001). The types of malperfusion in groups A and B were: cerebral (35% vs. 37%), peripheral extremities (40% vs. 48%), visceral (32% vs. 13%), and renal (39% vs. 35%). In group A, most patients received hemi-arch repair (62%), and only some patients underwent total arch repair (26%). All patients in group B underwent total arch repair with FET implantation. The 30-day mortality was 49% (n=52) in group A and 20% (n=9) in group B (p=0.001). Rates for other complications such as stroke, dialysis and rethoracotomy were comparable in both groups. Long-term survival was significantly different in the two groups: at 5 years after surgery, survival was 30% in group A and 60% in group B (p=0.0039).

Conclusion: In the present study, the FET procedure lead to a signifcant reduction in 30-day mortality when compared to conventional arch repair. The stent portion of the FET re-expands and stabilizes the true lumen, thereby eliminating malperfusion. Further, FET lead to a significant improvement of long-term survival . We conclude that the FET procedure is an effective treatment option for patients with malperfusion in the setting of AATDA. The FET procedure should be considered when evaluating patients with AADTA with malperfusion for surgery.

Identify the source of the funding for this research project: Internal funding