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Aortic remodeling, distal stent-graft induced new entry and endoleak following frozen elephant trunk: A systematic review and meta-analysis
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  • Pooria Nakhaei,
  • Matti Jubouri,
  • Mohamad Bashir,
  • Sepideh Banar,
  • Saba Ilkhani,
  • Elahe Zare Borzeshi,
  • Yousef Rezaei,
  • Mostafa Mousavizadeh,
  • Niki Tadayon,
  • Mohammed Idhrees,
  • Saeid Hosseini
Pooria Nakhaei
Rajaie Cardiovascular Medical and Research Center
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Matti Jubouri
Hull York Medical School
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Mohamad Bashir
Rajaie Cardiovascular Medical and Research Center
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Sepideh Banar
Rajaie Cardiovascular Medical and Research Center
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Saba Ilkhani
Shohada-e Tajrish Hospital
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Elahe Zare Borzeshi
Shahid Beheshti University of Medical Sciences School of Public Health and Safety
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Yousef Rezaei
Rajaie Cardiovascular Medical and Research Center
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Mostafa Mousavizadeh
Rajaie Cardiovascular Medical and Research Center
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Niki Tadayon
Shahid Beheshti University of Medical Sciences
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Mohammed Idhrees
SRM Institutes for Medical Science Vadapalani
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Saeid Hosseini
Rajaie Cardiovascular Medical and Research Center
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Abstract

Background: The introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortovascular surgery. However, although FET yields excellent results, the risk of certain complications requiring secondary intervention remains present, negating its one-step hybrid advantage over conventional techniques. This systematic review and meta-analysis sought to evaluate controversies regarding the incidence of FET-related complications, with a focus on aortic remodeling, distal stent-graft induced new entry (dSINE) and endoleak, in patients with type A aortic dissection (TAAD) and/or thoracic aortic aneurysm. Materials and methods: A comprehensive literature search was conducted using multiple electronic databases including EMBASE, Scopus, and PubMed/MEDLINE to identify evidence on TAR with FET in patients with TAAD and/or aneurysm. Studies published up until January 2022 were included, and after applying exclusion criteria, a total of 43 studies were extracted. Results: A total of 5068 patients who underwent FET procedure were included. The pooled estimates of dSINE and endoleak were 2% (95% CI 0.01-0.06, I 2 = 78%) and 3% (95% CI 0.01-0.11, I 2 = 89%), respectively. The pooled rate of secondary thoracic endovascular aortic repair (TEVAR) post-FET was 7% (95% CI 0.05-0.12, I 2 = 89%) whilst the pooled rate of false lumen thrombosis at the level of stent-graft was 91% (95% CI 0.75-0.97, I 2 = 92%). After subgroup analysis, heterogeneity for dSINE and endoleak resolved among European patients, where Thoraflex Hybrid and E-Vita stent-grafts were used (both I 2 = 0%). In addition, heterogeneity for secondary TEVAR after FET resolved among Asians receiving Cronus (I 2 = 15.1%) and Frozenix stent -grafts (I 2 = 1%). Conclusion: Our results showed that the FET procedure in patients with TAAD and/or aneurysm is associated with excellent results, with a particularly low incidence of dSINE and endoleak as well as highly favorable aortic remodeling. However the type of stent-graft and the study location were sources of heterogeneity, emphasizing the need for multicenter studies directly comparing FET grafts. Finally, Thoraflex Hybrid can be considered the primary FET device choice due to its superior results.
23 Jul 2022Submitted to Journal of Cardiac Surgery
26 Jul 2022Assigned to Editor
26 Jul 2022Submission Checks Completed
26 Jul 2022Reviewer(s) Assigned
27 Jul 2022Review(s) Completed, Editorial Evaluation Pending
27 Jul 2022Editorial Decision: Accept