Midterm results of aortic arch replacement with frozen elephant trunk for chronic dissecting aortic aneurysm involving the aortic arch

We performed total aortic arch replacement (TAR) with a frozen elephant trunk (FET) for chronic dissecting aortic aneurysm (DAA) involving the aortic arch as the initial surgery and carefully observed these aortic findings with periodic computed tomography (CT) follow-up. Additional surgical interventions were considered when aortic events were observed. Midterm outcomes were evaluated to clarify the feasibility of this strategy. Thirty-seven patients underwent TAR with FET between 2014 and 2020. The median follow-up period was 48.6 months. There was 1 case of operative mortality (2.7%) and 11 late deaths, including five aortic-related deaths. Aortic events occurred in 26 patients (72.2%), including 14 cases of stent-induced new entry (SINE), eight cases of aneurysmal enlargement, two cases of graft infection, and one each of additional aortic dissection and aortic root enlargement. Thirty-one procedures were performed, including 14 open surgeries, 16 thoracic endovascular aortic repairs (TEVAR), and 1 endovascular aortic repair (EVAR) with coil embolization. The freedom rate from aortic events was 36.9% at three years and 22.8% at five years. The distal aortic arch showed significant shrinking (slope, -1.96; P<0.001), but the lower descending aorta showed significant enlargement (slope, 0.87; P<0.001). The diameter of the middle descending aorta was a predictor of SINE (>40.5 mm) and aneurysm enlargement (>40.2 mm). The present study showed acceptable early outcomes but frequent aortic events during follow-up. Cautious periodic CT is mandatory to perform additional reinterventions at the proper time, and scheduled surgical intervention, including TEVAR, is essential for cases with enlarged middle descending aortas.