Frozen elephant trunk in total arch replacement: A systematic review and meta-analysis of outcomes and aortic proximalization

J Card Surg. 2021 Jun;36(6):1922-1934. doi: 10.1111/jocs.15452. Epub 2021 Mar 4.


Background and aim of the study: The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well as the predictors of outcomes are poorly identified. This systematic review and meta-analysis explore FET outcomes and its predictors with a focus on zone aortic proximalization.

Methods: We searched PubMed/MEDLINE, EMBASE, and Scopus databases from their beginning to June 2020 to find studies reporting the outcomes of the FET procedure for the total arch replacement (TAR).

Results: A total of 64 studies including 7967 patients were evaluated. The pooled estimates of cerebrovascular accidents, paraplegia, renal failure, and in-hospital mortality were 7.104 (95% confidence interval [CI], 5.691-8.661; I2 = 78.53%), 3.465 (95% CI, 2.852-4.136; I2 = 15.96), 14.969 (95% CI, 11.361-18.977; I2 = 91.26%), and 8.933 (95% CI, 7.128-10.919; I2 = 78.51%), respectively. Stratification by the geographical locations and by the aortic pathologies led to lower heterogeneity, but not for renal failure. The distal anastomosis in Zone 2 was associated with a lower rate of renal failure compared with Zone 3 (odds ratio, 0.54; 95% CI, 0.36-0.81; p = .003; I2 = 0%).

Conclusions: The FET procedure for TAR can be performed with acceptable mortality and morbidities among patients with complex aortic pathologies. Moreover, the distal anastomosis in Zone 2 was associated with lower renal failure compared to Zone 3.

Keywords: aorta; aortic aneurysm; aortic arch; aortic dissection; frozen elephant trunk.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Aorta, Thoracic / surgery
  • Aortic Aneurysm* / surgery
  • Aortic Aneurysm, Thoracic* / surgery
  • Aortic Dissection* / surgery
  • Blood Vessel Prosthesis Implantation*
  • Humans
  • Retrospective Studies