Frozen elephant trunk repair of aortic aneurysms: How to reduce the incidence of endoleak and reintervention

BACKGROUND: Frozen elephant trunk (FET) enables treatment of arch and proximal descending thoracic aorta aneurysms. In treating patients with single-stage FET, the relationship of distal stent size to endoleak and reintervention has remained unexamined. METHODS: In this retrospective analysis of 63 cases in which FET was used to repair aneurysms between 2008 and 2019, 36 were intended as single-stage procedures. Effective sizing and sealing of distal stents were analyzed by preoperative and postoperative computed tomography angiography (CTA). RESULTS: During a mean of 25.8 ± 5.7 months of CTA follow-up, 10 of 36 (28%) experienced endoleak, and 3 of 36 (8%) had sac expansion. Ultimately, 5 of 13 (38%) underwent thoracic endovascular aneurysm repair. Patients without endoleak or sac expansion were more likely to have stents with >10% oversize and a >30-mm seal in healthy aorta compared with those experiencing these complications (11 of 23 vs 0 of 13; P = .0031). Conversely, 11 of 36 patients (31%) with adequately oversized and sealed stents developed fewer endoleaks compared with those without (0 of 11 vs 10 of 14; P < .0004). Patients with endoleak or sac expansion had smaller mean distal stent oversize and shorter mean sealing length compared with those without endoleak or sac expansion (2.3 ± 3.9% vs 18 ± 2.9% [P = .0023] and 1 ± 0.7 mm vs 34 ± 6 mm [P = .0005], respectively). CONCLUSIONS: We recommend >10% distal stent oversize and >30-mm sealing length to minimize endoleak and reintervention. Increasing multidisciplinary collaboration with endovascular surgeons will improve distal stent planning.