The modified frozen elephant trunk may outperform limited and extended-classic repair in acute type I dissection
Eric E. Roselli, Benjamin Kramer, Emídio Germano, Andrew J. Toth, Patrick R. Vargo, Faisal G. Bakaeen, Venu Menon, Eugene H. Blackstone, Marc Gillinov, Gösta Pettersson, Edward G. Soltesz, Lars G. Svensson, Daniel Burns, Kevin I. Hodges, Marijan Koprivanac, Francis J. Caputo, Sean P. Lyden, Levester Kirksey, Jon G. Quatromoni, Ali Khalifeh, Milind Y. Desai, Vidyasagar Kalahasti, Brian P. Griffin, Richard H. Grimm, Paul Cremer, Bo Xu, Donald Hammer, Jay Ramchand, Maran Thamilarasan, Neha Quatromoni, Penelope Rampersad, Christine Jellis, Paul Schoenhagen, Michael A. Bolen, Christina Rigelsky, John Apostalakis, Andrew M. Bauer
Abstract
OBJECTIVES: A better surgical approach for acute DeBakey type I dissection has been sought for decades. We compare operative trends, complications, reinterventions and survival after limited versus extended-classic versus modified frozen elephant trunk (mFET) repair for this condition. METHODS: From 1 January 1978 to 1 January 2018, 879 patients underwent surgery for acute DeBakey type I dissection at Cleveland Clinic. Repairs were limited to the ascending aorta/hemiarch (701.79%) or extended through the arch [extended classic (88.10%) or mFET (90.10%)]. Weighted propensity score matched established comparable groups. RESULTS: Among weighted propensity-matched patients, mFET repair had similar circulatory arrest times and postoperative complications to limited repair, except for postoperative renal failure, which was twice as high in the limited group [25% (n = 19) vs 12% (n = 9), P = 0.006]. Lower in-hospital mortality was observed following limited compared to extended-classic repair [9.1% (n = 7) vs 19% (n = 16), P = 0.03], but not after mFET repair [12% (n = 9) vs 9.5% (n = 8), P = 0.6]. Extended-classic repair had higher risk of early death than limited repair (P = 0.0005) with no difference between limited and mFET repair groups (P = 0.9); 7-year survival following mFET repair was 89% compared to 65% after limited repair. Most reinterventions following limited or extended-classic repair underwent open reintervention. All reinterventions following mFET repair were completed endovascularly. CONCLUSIONS: Without increasing in-hospital mortality or complications, less renal failure and a trend towards improved intermediate survival, mFET may be superior to limited or extended-classic repair for acute DeBakey type I dissections. mFET repair facilitates endovascular reintervention, potentially reducing future invasive reoperations and warranting continued study.