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Evaluating the risk of spinal cord ischemia in zone 2 frozen elephant trunk replacement

  • Cenea Kemp
    Affiliations
    Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    University of Colorado School of Medicine, Aurora, CO, USA
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  • Christian V. Ghincea
    Affiliations
    Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    University of Colorado School of Medicine, Aurora, CO, USA
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  • Zihan Feng
    Affiliations
    University of Colorado School of Medicine, Aurora, CO, USA
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  • Anna K. Gergen
    Affiliations
    Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    University of Colorado School of Medicine, Aurora, CO, USA
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  • Joseph C. Cleveland
    Affiliations
    Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    University of Colorado School of Medicine, Aurora, CO, USA
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  • Jessica Y. Rove
    Affiliations
    Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    University of Colorado School of Medicine, Aurora, CO, USA
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  • Muhammad Aftab
    Affiliations
    Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    University of Colorado School of Medicine, Aurora, CO, USA
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  • David Fullerton
    Affiliations
    Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    University of Colorado School of Medicine, Aurora, CO, USA
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  • T. Brett Reece
    Correspondence
    Corresponding author. Cardiothoracic Surgery University of Colorado School of Medicine/Anschutz Medical Center Department of Surgery, Division of Cardiothoracic Surgery 12631 E. 17th Avenue, MS C-302, Aurora, CO, 80045, USA.
    Affiliations
    Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    Department of Surgery, University of Colorado Anschutz Medical Center, Aurora, CO, USA

    University of Colorado School of Medicine, Aurora, CO, USA
    Search for articles by this author

      Highlights

      • Frozen Elephant Trunk has facilitate open and Endovascular Completion of extensive Aortic pathology .
      • Stent Length has been a focus of morbidity rather than actual coverage of the descending thoracic aorta .
      • Utilization of 15 cm Stent from Zone 2 is safe, while facilitating distal reintervention when needed .

      Abstract

      Background

      The appropriate stent length in frozen elephant trunk replacements (FET) remains debated relative to the risk for paraplegia. However, landing the distal end of the stent beyond the curve of the arch facilitates distal reintervention, which is commonly beyond the 10 cm stent coverage when deployed proximal to the left subclavian artery. The aim of this study was to evaluate outcomes following the use of 15 cm stent grafts in zone 2 (z2, distal to the left common carotid).

      Methods

      Using our single institution-maintained database, 103 zone 2 FET performed from 2016 to 2020 were reviewed.

      Results

      Of the 103 z2, a 15 cm stent graft was used in 51 operations. The indications for FET included acute and chronic aortic dissection, arch aneurysms, and pseudoaneurysms. The incidence of SCI was 0%. Seven deaths (13.7%) occurred.

      Conclusions

      The data demonstrates the incidence of post-operative paraplegia to be 0% with 15 cm z2 FET. The understanding of SCI in FET should not only include the stent length but also from where it begins.

      Keywords

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      References

        • Papakonstantinou N.A.
        • Antonopoulos C.N.
        • Baikoussis N.G.
        • Kakisis I.
        • Geroulakos G.
        Frozen elephant trunk: an alternative surgical weapon against extensive thoracic aorta disease. A three-year meta-analysis.
        Heart Lung Circ. 2019; 28: 213-222
        • Borst H.G.
        • Walterbusch G.
        • Schaps D.
        Extensive aortic replacement using "elephant trunk" prosthesis.
        Thorac Cardiovasc Surg. 1983; 31 (Feb) (PMID: 6189250): 37-40https://doi.org/10.1055/s-2007-1020290
        • Borst H.G.
        • Frank G.
        • Schaps D.
        Treatment of extensive aortic aneurysms by a new multiple-stage approach.
        J Thorac Cardiovasc Surg. 1988; 95 (Jan) (PMID: 3336224): 11-13
        • Kreibich M.
        • Berger T.
        • Morlock J.
        • et al.
        The frozen elephant trunk technique for the treatment of acute complicated type B aortic dissection.
        Eur J Cardio Thorac Surg. 2018; 53: 525-530
        • Ma M.
        • Feng X.
        • Wang J.
        • et al.
        Acute type I aortic dissection: a propensity-matched comparison of elephant trunk and arch debranching repairs.
        Interact Cardiovasc Thorac Surg. 2018; 26: 183-189
        • Shrestha M.
        • Kaufeld T.
        • Beckmann E.
        • et al.
        Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: single-center results of the first 100 patients.
        J Thorac Cardiovasc Surg. 2016; 152 (e1): 148-159
        • Flores J.
        • Kunihara T.
        • Shiiya N.
        • Yoshimoto K.
        • Matsuzaki K.
        • Yasuda K.
        Extensive deployment of the stented elephant trunk is associated with an increased risk of spinal cord injury.
        J Thorac Cardiovasc Surg. 2006; 131: 336-342
        • Preventza O.
        • Liao J.L.
        • Olive J.K.
        • et al.
        Neurologic complications after the frozen elephant trunk procedure: a meta-analysis of more than 3000 patients.
        J Thorac Cardiovasc Surg. 2020; 160 (Jul) (e4, Epub 2019 Oct 17): 20-33https://doi.org/10.1016/j.jtcvs.2019.10.031
        • Geisbüsch S.
        • Stefanovic A.
        • Koruth J.S.
        • et al.
        Endovascular coil embolization of segmental arteries prevents paraplegia after subsequent thoracoabdominal aneurysm repair: an experimental model.
        J Thorac Cardiovasc Surg. 2014; 147: 220-226
        • Etz C.D.
        • Zoli S.
        • Mueller C.S.
        • et al.
        Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair.
        J Thorac Cardiovasc Surg. 2010; 139: 1464-1472
        • Hawkins R.B.
        • Mehaffey J.H.
        • Narahari A.K.
        • et al.
        Improved outcomes and value in staged hybrid extent II thoracoabdominal aortic aneurysm repair.
        J Vasc Surg. 2017; 66: 1357-1363
        • Fillinger M.F.
        • Greenberg R.K.
        • McKinsey J.F.
        • Chaikof E.L.
        Society for vascular surgery ad hoc committee on TEVAR reporting standards. Reporting standards for thoracic endovascular aortic repair (TEVAR).
        J Vasc Surg. 2010; 52 (Oct) (1033.e15, PMID: 20888533): 1022-1033https://doi.org/10.1016/j.jvs.2010.07.008
        • Poon S.S.
        • Tian D.H.
        • Yan T.
        • et al.
        International Aortic Arch Surgery Study Group. Frozen elephant trunk does not increase incidence of paraplegia in patients with acute type A aortic dissection.
        J Thorac Cardiovasc Surg. 2020; 159 (Apr) (e1, Epub 2019 Apr 14. PMID: 31126657): 1189-1196https://doi.org/10.1016/j.jtcvs.2019.03.097
        • Eldeiry M.
        • Aftab M.
        • Bergeron E.
        • et al.
        The buffalo trunk technique for aortic arch reconstruction.
        Ann Thorac Surg. 2019; 108 (Sep) (Epub 2019 Apr 11. PMID: 30981849): 680-686https://doi.org/10.1016/j.athoracsur.2019.03.034
        • Bachet J.
        Open repair techniques in the aortic arch are still superior.
        Ann Cardiothorac Surg. 2018; 7: 328-344
        • Miyamoto Y.
        Elephant trunk technique for hybrid aortic arch repair.
        Gen Thorac Cardiovasc Surg. 2014; 62 (Mar) (Epub 2013 Aug 15): 135-141https://doi.org/10.1007/s11748-013-0299-0
        • Liakopoulos O.J.
        Commentary: spinal cord injury after the frozen elephant trunk procedure: are we really safe now?.
        J Thorac Cardiovasc Surg. 2020; 159 (Apr) (Epub 2019 Apr 24): 1199-1200https://doi.org/10.1016/j.jtcvs.2019.04.008
        • Chakos A.
        • Jbara J.
        • Yan T.D.
        • Tian D.H.
        Long-term survival and related outcomes for the hybrid versus the traditional arch repair – a meta-analysis.
        Ann Cardiothorac Surg. 2018; 7: 319-327
        • Etz C.D.
        • Zoli S.
        • Mueller C.S.
        • et al.
        Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal aortic aneurysm repair.
        J Thorac Cardiovasc Surg. 2010; 139: 1464-1472
        • Crawford E.S.
        Thoraco-abdominal and abdominal aortic aneurysms involving renal, superior mesenteric, celiac arteries.
        Ann Surg. 1974; 179: 763-772
        • Etz C.D.
        • Kari F.A.
        • Mueller C.S.
        • Brenner R.M.
        • Lin H.M.
        • Griepp R.B.
        The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrifice.
        J Thorac Cardiovasc Surg. 2011; 141: 1029-1036
        • Nishi H.
        • Mitsuno M.
        • Tanaka H.
        • Ryomoto M.
        • Fukui S.
        • Miyamoto Y.
        Spinal cord injury in patients undergoing total arch replacement: a cautionary note for use of the long elephant technique.
        J Thorac Cardiovasc Surg. 2011; 142 (Nov) (Epub 2011 May 25. PMID: 21616508): 1084-1089https://doi.org/10.1016/j.jtcvs.2010.06.069