Endovascular repair of residual intimal tear or distal new entry after frozen elephant trunk for type A aortic dissection.

Background: In patients with type A dissection, residual dissection and new distal entry tears following the frozen elephant trunk (FET) procedure adversely affect long-term prognosis. Management include open and endovascular repair, while clinical experience is limited. We evaluate the efficacy of thoracic endovascular aortic repair (TEVAR) in management of residual intimal tear or distal new entry tear following FET in patients with type A aortic dissection (TAAD).

Methods: Between May 2003 and April 2013, we performed FET and total arch replacement for 1,003 patients with TAAD. Among these, 23 patients (2.3%) required TEVAR for distal new entry (n=2) or residual intimal tear (n=21) at a mean of 2.0±1.6 years after FET. Mean age was 50.1±11.5 years. Marfan syndrome was seen in 2 patients (8.7%).

Results: Procedural success was 100%. The distal landing zone was above the 11th thoracic vertebra (T11) in 86.9% (20/23). Neither death nor any paraplegia or stroke occurred early after TEVAR. Follow-up was complete in 100% averaging 2.8±1.7 years (0.3-6.4). One non-Marfan patient died of distal aortic rupture at 4 months after TEVAR. No late stroke or paraplegia occurred. Survival was 95.7% (95% CI, 72.9-99.4%) at 3 and 5 years, respectively. CTA detected false lumen obliteration by thrombus around the endograft in the descending aorta in 91.3% (21/23) of patients.

Conclusions: These early and midterm outcomes show the efficacy of TEVAR in obliterating the residual intimal tear or distal new entry after FET in patients with TAAD. TEVAR may be an alternative approach to distal new entry or residual intimal tear following FET for patients with TAAD.