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Commentary: Total aortic arch replacement and the frozen elephant trunk: Out with the old, in with the new?

  • Erik Beckmann
    Affiliations
    Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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  • Axel Haverich
    Correspondence
    Address for reprints: Axel Haverich, MD, Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Carl-Neuberg Str 1, 30625 Hannover, Germany.
    Affiliations
    Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
    Search for articles by this author
      The frozen elephant trunk procedure can be widely performed with extremely low perioperative risk.
      See Article page 1681.
      In this issue of the Journal, Ogino and colleagues
      • Ogino H.
      • Okita Y.
      • Uchida N.
      • Kato M.
      • Miyamoto S.
      • Matsuda H.
      • et al.
      Comparative study of Japanese frozen elephant trunk device for open aortic arch repairs.
      present the early results of the Japanese multicenter study comparing conventional total aortic arch replacement with the frozen elephant trunk procedure using the Frozenix J-graft. Over a 3-year period, 684 patients underwent surgery with 1 of these operations. The early mortality was impressively low, as were the rates for most perioperative complications. Thus, the authors conclude that the frozen elephant trunk provides acceptable outcomes.
      This study aimed to compare conventional arch replacement and frozen elephant trunk, but how successful can such a comparison be? Is it possible to deduce a “simply better” procedure? Obviously, the authors cannot answer simplistic questions like this, even though it would make life easier. Rather, they highlight advantages of the frozen elephant trunk and its drawbacks. The nuanced take: Wide application of the frozen elephant trunk is certainly justified by its low perioperative risks, but the traditional procedure remains relevant in modern practice for selected patients.
      The frozen elephant trunk appears to benefit patients with acute aortic dissection by reexpansion of the true lumen immediately and stabilization of the distal aorta in the long term.
      • Shrestha M.
      • Bachet J.
      • Bavaria J.
      • Carrel T.P.
      • De Paulis R.
      • Di Bartolomeo R.
      • et al.
      Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the vascular domain of EACTS.
      ,
      • Chen Y.
      • Ma W.-G.
      • Zhi A.-H.
      • Lu L.
      • Zheng J.
      • Zhang W.
      • et al.
      Fate of distal aorta after frozen elephant trunk and total arch replacement for type A aortic dissection in Marfan syndrome.
      In this study, the frozen elephant trunk was more commonly applied in patients with acute aortic dissection, supporting this idea. The authors focus exclusively on short-term outcomes. Especially in the context of aortic dissection, the long-term outcomes of the frozen elephant trunk procedure are of great interest.
      The relatively low but still-heightened risk of spinal cord ischemia is a potential disadvantage of the frozen elephant trunk compared with conventional arch replacement.
      • Hagl C.
      • Pichlmaier M.
      • Khaladj N.
      Elephant trunks in aortic surgery: fresh and frozen.
      In this study, the rate of paraplegia was 1.6% in the frozen elephant trunk group, whereas it was 0% in the conventional group. Such measures as cerebrospinal fluid drainage, proximalization of the distal anastomosis, and use of a short stent graft should be taken to reduce this risk.
      • Hagl C.
      • Pichlmaier M.
      • Khaladj N.
      Elephant trunks in aortic surgery: fresh and frozen.
      Furthermore, some patients' pathologies may not require frozen elephant trunk. Using conventional arch replacement instead avoids the risk of spinal cord injury completely. Thus, careful patient selection is important.
      The study by Ogino and colleagues demonstrates today's widespread and extremely safe use of the frozen elephant trunk procedure in Japan. Even though the Frozenix J graft is not available in Europe and the United States, the results are of relevance, especially in the context of the upcoming introduction of the Thoraflex hybrid graft as the first commercially available hybrid graft in the United States.
      • Shrestha M.
      • Kaufeld T.
      • Beckmann E.
      • Fleissner F.
      • Umminger J.
      • Abd Alhadi F.
      • et al.
      Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: single-center results of the first 100 patients.
      As the present study shows, the availability of off-the-shelf solutions facilitates the spread of hybrid grafts, which in turn improves the safety of the operation. Practice makes perfect.

      References

        • Ogino H.
        • Okita Y.
        • Uchida N.
        • Kato M.
        • Miyamoto S.
        • Matsuda H.
        • et al.
        Comparative study of Japanese frozen elephant trunk device for open aortic arch repairs.
        J Thorac Cardiovasc Surg. 2022; 164: 1681-1692.e2
        • Shrestha M.
        • Bachet J.
        • Bavaria J.
        • Carrel T.P.
        • De Paulis R.
        • Di Bartolomeo R.
        • et al.
        Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the vascular domain of EACTS.
        Eur J Cardio-Thorac Surg. 2015; 47: 759-769
        • Chen Y.
        • Ma W.-G.
        • Zhi A.-H.
        • Lu L.
        • Zheng J.
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        • et al.
        Fate of distal aorta after frozen elephant trunk and total arch replacement for type A aortic dissection in Marfan syndrome.
        J Thorac Cardiovasc Surg. 2019; 157: 835-849
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        • Pichlmaier M.
        • Khaladj N.
        Elephant trunks in aortic surgery: fresh and frozen.
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        • Kaufeld T.
        • Beckmann E.
        • Fleissner F.
        • Umminger J.
        • Abd Alhadi F.
        • 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: 148-159.e1

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