Open or endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology after frozen elephant trunk: perioperative and mid-term outcomes

OBJECTIVES: The aim of this study was to evaluate the outcomes of open and endovascular treatment of downstream thoracic or thoraco-abdominal aortic pathology in patients who underwent previous frozen elephant trunk (FET). METHODS: Data were retrieved to evaluate mortality, cardiac, pulmonary, cerebrovascular, renal and spinal cord major adverse events, early- and mid-term reintervention and survival rates. The Society for Vascular Surgery endovascular reporting standards were used. RESULTS: From 2011 to 2020, 48 patients (36 males, median age 60 years) underwent downstream aortic repair at a median of 18 months (interquartile range: 6-57) after the initial FET. Twenty-eight patients (58.3%) received open and 20 (41.7%) endovascular repair. The overall 30-day mortality was 6.3% and the initial clinical success was 88%, with no inter-group differences (P = 0.22 and 0.66 respectively). Six spinal cord deficits were recorded (13%): 3 (6.3%) were permanent. The major adverse events incidence was lower in the endovascular cohort [4 (20%) vs 14 (50%); P = 0.047], mainly due to a lower rate of grade >= 2 respiratory complications (5% vs 42.9%; P=0.004). Assisted primary clinical success at 5 years was higher in the endovascular group (95% vs 68%, P = 0.022); freedom from reintervention at competing risk analysis (P=0.3) and overall survival at Kaplan-Meier curves (log-rank P=0.29) were similar. CONCLUSIONS: Downstream aortic repair after FET is feasible with both open and endovascular repair with acceptable mortality and permanent paraplegia rates. The endovascular approach has potential perioperative and mid-term advantages, but long-term durability has to be further investigated in larger cohorts.

Automated summary

This study evaluated the outcomes of open and endovascular treatment for downstream aortic pathology in patients who previously underwent frozen elephant trunk (FET) repair, finding that the endovascular treatment group had lower incidence of major adverse events and higher assisted primary clinical success rate at 5 years.