Aortic remodelling in aortic dissection after frozen elephant trunk: overcoming the challenges

J Cardiovasc Surg (Torino). 2022 May 27. doi: 10.23736/S0021-9509.22.12385-2. Online ahead of print.

Abstract

Introduction: The introduction of the single-step hybrid frozen elephant trunk (FET) procedure expanded the surgeon's armamentarium in managing aortic dissection (AD). This is evident by the reduction in mortality and complication rates associated with conventional techniques used to repair ADs. Although FET still carries a risk of certain complications, it has been associated with excellent aortic remodelling following the procedure. The main scope of this review is to evaluate aortic remodelling in aortic dissection after FET as well as to highlight the challenges that may arise and ways to overcome them.

Evidence acquisition: A comprehensive literature search was conducted on multiple electronic databases including PubMed, Ovid, Scopus and Embase to highlight the evidence in the literature on aortic remodelling in aortic dissection after FET.

Evidence synthesis: The FET procedure promotes excellent long-term remodelling, this is seen in the substantial increase in the size of the true lumen along with the decrease in that of the false lumen (FL), in addition to significant FL thrombosis. However, this occurs to a lesser extent more distally at the level of the abdominal aorta. Negative remodelling may present a major challenge to the process of aortic remodelling, nevertheless, this can be overcome with endovascular reintervention which has demonstrated highly favourable results. Additionally, the choice of FET graft, in terms of type and length, seems to influence outcomes. Namely, the Thoraflex™ Hybrid graft can be considered the superior graft on the global market. On the other hand, there seems to be a debate in the literature on the optimal FET graft length.

Conclusions: The FET procedure has revolutionised the field of aortovascular surgery and promotes excellent long-term aortic remodelling. Negative remodelling can occur but can also be favourably overcome with endovascular reintervention. Finally, the choice of FET graft may also influence results, thus, should be taken with great care.