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Features and risk factors of early intraluminal thrombus formation within the frozen elephant trunk stent graft.

Published:January 23, 2023DOI:https://doi.org/10.1016/j.jtcvs.2023.01.014
Features and risk factors of early intraluminal thrombus formation within the frozen elephant trunk stent graft.
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      Abstract:

      Objective

      The frozen elephant trunk (FET) is a standard treatment method for aortic arch pathologies extending into the descending aorta. We previously described the phenomenon of early postoperative intraluminal thrombosis (ILT) within the FET. We investigated the features and predictors of ILT.

      Methods

      281 patients (66% male, mean age 60±12 years) underwent FET implantation between 05/10 and 11/19. In 268 patients (95%) early postoperative computed tomography angiography (CTA) was available to assess ILT.

      Results

      Incidence of ILT after FET implantation was 8.2%. ILT was diagnosed early after the procedure (4.6 ± 2.9 days) and could be successfully treated with anticoagulation in 55% of patients. 27% developed embolic complications. Mortality (27 vs. 11%, P=0.044) and morbidity were significantly higher in ILT patients. Our data showed a significant association of ILT with prothrombotic medical conditions and anatomical slow flow features. The incidence of heparin induced thrombopenia was higher in ILT patients (18 vs. 3.3%, P=0.011). Stent graft diameter index, anticipated endoleak Ib, and degenerative aneurysm were significant independent predictors of ILT. Therapeutic anticoagulation was a protective factor. Glomerular filtration rate, extracorporeal circulation time, postoperative re-thoracotomy, and ILT (OR 3.19, P=0.047) were independent predictors of perioperative mortality.

      Conclusions

      ILT is a underrecognised complication after FET implantation. In patients with risk factors of ILT indication for FET should be carefully evaluated and postoperative anticoagulation considered. Early TEVAR extension should be considered in patients with ILT to prevent embolic complications. Stent graft designs should be improved to prevent ILT after FET implantation.

      Graphical abstract

      Figure thumbnail fx1
      Graphical Abstract

      Keywords

      Glossary of Abbreviations:

      BMI (Body mass index), BSA (body surface area), CI (confidence interval), CTA (computed tomography angiography), ECC (extracorporeal circulation), FET (Frozen elephant trunk), FFP (fresh frozen plasma), GFR (glomerular filtration rate), HCA (hypothermic circulatory arrest), HIT (heparin induced thrombopenia), ICU (intensive care unit), ILT (intraluminal thrombus), INR (international normalized ratio), IQR (interquartile range), MRI (magnetic resonance imaging), OR (Odds ratio), PBC (packed blood cells), PC (platelet concentrate), POD (postoperative day), PTT (partial thromboplastin time), SACP (selective antegrade cerebral perfusion), VSARR (valve sparing aortic root replacement)
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      Article info

      Publication history

      Accepted: January 17, 2023
      Received in revised form: December 6, 2022
      Received: June 3, 2022

      Publication stage

      In Press Journal Pre-Proof

      Footnotes

      Sources of Funding: none.

      Conflicts of interest: Shrestha M. and Haverich A. declare that they served as consultants for Terumo Aortic during the study period. All other authors declare that they have no conflicts of interest.

      Institutional Review Board Approval: IRB #1698-2013 (January 25th, 2013); IRB #10162_BO_K_2022 (January 14th, 2022). Informed consent was obtained.

      Central Message:

      Frozen elephant trunk implantation may lead to intraluminal thrombosis within the stent graft. Therapeutic anticoagulation should be considered in patients at risk. Early imaging should be performed.

      Perspective Statement:

      We believe that the incidence of ILT after FET implantation is underreported in our study. Further research should focus on early postoperative imaging and risk stratification. Stent graft designs should be improved to reduce surface thrombogenicity and slow flow areas within the stent grafts.

      Central Picture Legend: Intraluminal thrombosis within a frozen elephant trunk graft on postoperative day 8.

      Identification

      DOI: https://doi.org/10.1016/j.jtcvs.2023.01.014

      Copyright

      © 2023 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery

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