Distal Repair After Total Aortic Arch Replacement With Frozen Elephant Trunk in Patients With Chronic Multilevel Thoracic Aortic Disease

Objective To examine the management of distal aortic disease after total arch replacement with the frozen elephant trunk (TAR + FET) in patients with chronic thoracic aortic disease. Methods Two centre retrospective study of consecutive patients treated between January 2010 and December 2019. Primary endpoint was 30 day/in hospital mortality. Secondary end point was mid-term survival. Data are presented as median (IQR). Chi squared or Fisher’s exact test was used as appropriate. Estimated survival (standard error) was assessed by the calculating Kaplan–Meier product limit estimator with right censoring of survival data. A p value of < .050 was considered to be statistically significant. STROBE guidelines were followed. Results A total of 158 patients (72 men; median age 70, IQR 64, 75; median distal aortic diameter 58 mm (46, 68; 127 aneurysmal disease, 31 chronic dissection) underwent TAR + FET. Peri-operative mortality was 10.1% (9/107 elective, 7/51 non-elective). Of 74 (46.8%) patients with a primary distal seal, seven (9.5%) died peri-operatively, distal seal was maintained during follow up in 51, nine underwent late distal repair (two planned, seven unplanned; one open, eight endovascular; one peri-operative death) with a median interval to unplanned repair of 777 days (462, 1480), and seven with loss of seal had no intervention. Distal seal failed in 2/28 (7%) patients with a distal seal length > 30 mm and device oversizing > 10%, compared with 12/39 (31%) patients who did not meet these criteria (p = .031). In 84 patients without primary distal seal, nine (10.7%) died peri-operatively, the distal aorta remained below the size threshold for repair during follow up in 12 patients, 44 had distal repair (median aortic diameter 64 mm, 60, 75; eight open, one hybrid, 35 endovascular repairs; no mortality) at a median of 256 days (135, 740), and 19 did not have distal repair at the end of the follow up period: six died before planned repair at a median interval of 115 days (85, 120); eight were considered unfit; one was assessed as fit but declined; and four patients were awaiting assessment). Median follow up was 46 months (26, 75): no patients were lost to follow up. Estimated ± standard error five year survival was 61.5 ± 4.1%: elective 70.6 ± 4.7%, non-elective 43.2 ± 7.2%. Conclusion TAR + FET achieved primary distal seal in 47% of patients, but late failure occurred in 21% of patients. Distal repair was ultimately indicated in 84% of survivors without primary distal seal and of these 70% underwent repair, almost 10% died before planned repair, and 13% were considered unfit. Earlier distal endovascular repair and better assessment of patient fitness may improve mid-term outcomes.