Objective

Single-stage repair of concomitant aortic arch (AR) and descending thoracic aorta (DTA) lesions represent a significant challenge for the cardiovascular surgeon. In the modern era, the frozen elephant trunk (FET) allows surgical replacement of the AR and simultaneous stenting of the DTA. We aim to review the clinical outcome in these patients, in particular regarding the incidence of spinal cord injury (SCI).

Methods

We interrogated our prospectively maintained database and identified 57 FET procedures (2002-2014). Median (range) age was 69 (26-83) years (50% male). Median Logistic EuroSCORE was 20.2. Comorbidities included COPD in 20.8% of patients, arteriopathy in 39.5%, previous stroke or TIA 12.5%. Eighteen patients presented with urgent or emergency status (31.5%). Concomitant procedures included root replacement in 31.2% of patients, MVR/TVR in 8.4% and CABG in 10.4%.

Results

Thirty-day, in-hospital mortality and stroke rate were 15.8%, 17.4% and 3.5%, respectively. Preoperative planning consisted in avoiding full coverage of DTA (landing zone above T10 in all patients) and preservation of left subclavian artery (all but one patient). Postoperatively care was adjusted to maintain a mean systemic BP between 85 and 105 mmHg, a CI>2.4 l/min/m2, a UO>1 ml/Kg/min, a base excess of 0±5 with a pH>7.3 and an Hb >10 g/dl. There was one case of paraplegia (1.7%).

Conclusion

FET may be performed with satisfactory results and low incidence of complications. This approach may reduce overall mortality of two-stage approach, eliminating interval mortality. Strict preoperative planning and perioperative/postoperative monitoring of all haemodynamic and metabolic parameters with meticulous management of blood pressure allow excellent protection to the spinal cord. FET is however still complicated by an increased risk of mortality compared to conventional arch replacement.