Downstream thoracic endovascular aortic repair following zone 2, 100-mm stent graft frozen elephant trunk implantation

OBJECTIVES: The aim of this study was to analyse outcomes of downstream thoracic endovascular aortic repair (TEVAR) following the frozen elephant trunk (FET) procedure. METHODS: Sixty-six patients underwent downstream TEVAR following the FET procedure to treat thoracic aortic dissections (n = 42, 64%), aneurysms (n = 19, 29%) or penetrating aortic ulcers involving the aortic arch (n = 5, 8%). Patient and outcome characteristics were analysed. RESULTS: Downstream TEVAR was performed 7 [interquartile range: 2–18] months after the FET procedure in 39 male (59%) and 27 female (41%) patients aged 68 [interquartile range: 56, 75] years, including 11 patients (17%) with a connective tissue disease. Before TEVAR, cerebrospinal fluid drainage was put in place in 61 patients (92%). Patients were treated with 1 stent graft (n = 28, 42%), 2 stent grafts (n = 37, 56%) or 3 stent grafts (n = 1, 2%). The femoral artery was accessed through surgical cut-down (n = 15, 23%) or percutaneously (n = 49, 74%). One patient (2%) developed a temporary spinal cord injury that resolved spontaneously. No case of permanent spinal cord injury, stroke or death was observed. After 12 [interquartile range: 2–23] months, 15 patients required an additional aortic reintervention (endovascular: n = 6; surgical: n = 9). CONCLUSIONS: Downstream TEVAR following the FET procedure is associated with excellent clinical outcomes. We thus maintain that staging thoracic aortic repair—FET and secondary TEVAR—is a very successful and safe strategy. Certain patients might need a tertiary procedure to fix their entire aortic pathology; therefore, they will require long-term continuous follow-up, ideally in a dedicated aortic clinic.