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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
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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

      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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