The evolution of arch surgery: Frozen elephant trunk or conventional elephant trunk?

Frontiers in Cardiovascular Medicine, 2022 · DOI: 10.3389/fcvm.2022.999314 · Published: October 20, 2022

Cardiovascular Science Surgery Research Methodology & Design

Simple Explanation

Aortic arch aneurysms and dissections are serious conditions requiring complex surgery with high complication and mortality rates. The study compares two surgical techniques: the elephant trunk (ET) technique, a two-stage procedure, and the frozen elephant trunk (FET) technique, a single-stage procedure. The meta-analysis investigates the perioperative and early outcomes (up to 30 days) of ET versus FET, focusing on mortality, spinal cord injury (SCI), stroke, and renal failure. It also explores the effects of age and sex as cofactors. The results indicate that while ET was associated with higher early mortality, it also showed a lower incidence of SCI compared to FET. However, when analyzing studies published in the last 5 years, the differences in mortality and SCI between the two techniques were not significant.

Study Duration

1997-2019 (data collection), 2008-2021 (publication)

Participants

3153 patients (68.5% male)

Evidence Level

Systematic Review and Meta-Analysis

Key Findings

1
ET is associated with higher early mortality compared to FET (RR 1.37 [1.04 to 1.81], p = 0.027) when considering all studies published between 2008 and 2021.
2
FET is associated with a higher incidence of spinal cord injury (SCI) compared to ET (RR 0.53 [0.35 to 0.81], p = 0.004) across all studies.
3
When only studies published in the last 5 years (2017-2021) are analyzed, there are no significant differences in mortality or SCI between ET and FET.

Research Summary

This meta-analysis compares the outcomes of conventional elephant trunk (ET) and frozen elephant trunk (FET) techniques for aortic arch surgery, focusing on early mortality and major complications. The study found that ET was associated with higher early mortality but lower spinal cord injury rates compared to FET when considering all studies. However, recent studies (2017-2021) show no significant differences in these outcomes. The authors conclude that ET and FET show comparable results in complication and mortality rates, with improved outcomes in recent studies, suggesting advancements in both techniques. Future research should focus on prospective analysis and less invasive hybrid procedures.

Practical Implications

Surgical Technique Selection

Surgeons should consider the specific risks and benefits of each technique (ET vs. FET) when planning aortic arch surgery, particularly regarding early mortality and spinal cord injury. Patient-specific factors should also be considered.

Advancements in Techniques

The study highlights the importance of ongoing advancements in surgical techniques and devices for aortic arch surgery, as evidenced by the improved outcomes in more recent studies. Continuous learning and adoption of new techniques are crucial.

Future Research Directions

Future research should focus on prospective studies to reduce bias and explore less invasive hybrid procedures for aortic arch repair. Further investigation into long-term outcomes and the impact of specific devices is warranted.

Study Limitations

1
Lack of randomized controlled studies, leading to potential selection bias.
2
Heterogeneity in surgical techniques, devices used, and operator experience across the included studies.
3
Incomplete data for all examined outcomes in some of the included studies.

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