Commentary: Does the risk of paraplegia leave you cold?

Central MessagePatients may benefit from the use of frozen elephant trunk extension in total aortic arch replacement, although it may risk the development of paraplegia.See Article page 343. Patients may benefit from the use of frozen elephant trunk extension in total aortic arch replacement, although it may risk the development of paraplegia. See Article page 343. Despite more than a half a century of success, repair of the transverse aortic arch remains highly complex.1DeBakey M.E. Crawford E.S. Cooley D.A. Morris Jr., G.C. Successful resection of fusiform aneurysm of aortic arch with replacement by homograft.Surg Gynecol Obstet. 1957; 105: 657-664PubMed Google Scholar Repair is performed to treat aortic aneurysm or dissection and ranges from partial replacement (eg, hemiarch repairs) to total arch replacement and may extend beyond the arch into the proximal portion of the descending thoracic aorta (eg, elephant trunk and frozen elephant trunk approaches). Aortic arch repair has substantially changed in recent decades—temperature targets during hypothermic circulatory arrest have risen, the use of antegrade cerebral perfusion is widespread, cannulation sites have shifted away from the femoral artery, debranching techniques for the brachiocephalic arteries have been adopted, and more.2Coselli J.S. Green S.Y. Aortic arch repair today: open repair is best for most arch lesions.J Cardiovasc Surg (Torino). 2015; 56: 531-546PubMed Google Scholar, 3Svensson L.G. Blackstone E.H. Apperson-Hansen C. Ruggieri P.M. Ainkaran P. Naugle R.I. et al.Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial.J Thorac Cardiovasc Surg. 2015; 150: 1140-1147Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 4Di Bartolomeo R. Murana G. Di Marco L. Pantaleo A. Alfonsi J. Leone A. et al.Frozen versus conventional elephant trunk technique: application in clinical practice.Eur J Cardiothorac Surg. 2017; 51: i20-i28Crossref PubMed Scopus (64) Google Scholar, 5Hanif H. Dubois L. Ouzounian M. Peterson M.D. El-Hamamsy I. Dagenais F. et al.Aortic arch reconstructive surgery with conventional techniques vs frozen elephant trunk: a systematic review and meta-analysis.Can J Cardiol. 2018; 34: 262-273Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar Although this evolution of approach has reduced the risk of postoperative death and stroke for many patients, it is commonly accepted that both repair in the setting of acute type A aortic dissection and extended repair increase operative risk.5Hanif H. Dubois L. Ouzounian M. Peterson M.D. El-Hamamsy I. Dagenais F. et al.Aortic arch reconstructive surgery with conventional techniques vs frozen elephant trunk: a systematic review and meta-analysis.Can J Cardiol. 2018; 34: 262-273Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 6Crawford E.S. Kirklin J.W. Naftel D.C. Svensson L.G. Coselli J.S. Safi H.J. Surgery for acute dissection of ascending aorta. Should the arch be included?.J Thorac Cardiovasc Surg. 1992; 104: 46-59Abstract Full Text PDF PubMed Google Scholar To reduce operative risk in the setting of acute type A aortic dissection, many aortic centers tend to limit repair to partial arch replacement; however, the use of frozen elephant trunk approaches holds the promise of a long-term benefit by facilitating remodeling of the false lumen and subsequently reducing the possibility of late dilatation of the chronically dissected distal aorta that often necessitates further repair.7Berger T. Kreibich M. Morlock J. Kondov S. Scheumann J. Kari F.A. et al.True-lumen and false-lumen diameter changes in the downstream aorta after frozen elephant trunk implantation.Eur J Cardiothorac Surg. 2018; 54: 375-381Crossref PubMed Scopus (44) Google Scholar, 8Dohle D.S. Tsagakis K. Janosi R.A. Benedik J. Kuhl H. Penkova L. et al.Aortic remodelling in aortic dissection after frozen elephant trunk.Eur J Cardiothorac Surg. 2016; 49: 111-117Crossref PubMed Scopus (94) Google Scholar, 9Iafrancesco M. Goebel N. Mascaro J. Franke U.F.W. Pacini D. Di Bartolomeo R. et al.Aortic diameter remodelling after the frozen elephant trunk technique in aortic dissection: results from an international multicentre registry.Eur J Cardiothorac Surg. 2017; 52: 310-318Crossref PubMed Scopus (64) Google Scholar, 10Shrestha M. Kaufeld T. Beckmann E. Fleissner F. Umminger J. Abd Alhadi F. et al.Total aortic arch replacement with a novel 4-branched frozen elephant trunk prosthesis: single-center results of the first 100 patients.J Thorac Cardiovasc Surg. 2016; 152: 148-159 e1Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar But, there may be a downside to the use of frozen elephant trunk approaches as pertains to postoperative spinal cord deficit.4Di Bartolomeo R. Murana G. Di Marco L. Pantaleo A. Alfonsi J. Leone A. et al.Frozen versus conventional elephant trunk technique: application in clinical practice.Eur J Cardiothorac Surg. 2017; 51: i20-i28Crossref PubMed Scopus (64) Google Scholar, 5Hanif H. Dubois L. Ouzounian M. Peterson M.D. El-Hamamsy I. Dagenais F. et al.Aortic arch reconstructive surgery with conventional techniques vs frozen elephant trunk: a systematic review and meta-analysis.Can J Cardiol. 2018; 34: 262-273Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 11Shrestha M. Bachet J. Bavaria J. Carrel T.P. De Paulis R. Di Bartolomeo R. et al.Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the vascular domain of EACTS.Eur J Cardiothorac Surg. 2015; 47: 759-769Crossref PubMed Scopus (215) Google Scholar, 12Kozlov B.N. Panfilov D.S. Ponomarenko I.V. Miroshnichenko A.G. Nenakhova A.A. Maksimov A.I. et al.The risk of spinal cord injury during the frozen elephant trunk procedure in acute aortic dissection.Interact Cardiovasc Thorac Surg. 2018; 26: 972-976Crossref PubMed Scopus (16) Google Scholar The fact remains that paraplegia after aortic arch replacement is traditionally an uncommon event.2Coselli J.S. Green S.Y. Aortic arch repair today: open repair is best for most arch lesions.J Cardiovasc Surg (Torino). 2015; 56: 531-546PubMed Google Scholar, 4Di Bartolomeo R. Murana G. Di Marco L. Pantaleo A. Alfonsi J. Leone A. et al.Frozen versus conventional elephant trunk technique: application in clinical practice.Eur J Cardiothorac Surg. 2017; 51: i20-i28Crossref PubMed Scopus (64) Google Scholar, 5Hanif H. Dubois L. Ouzounian M. Peterson M.D. El-Hamamsy I. Dagenais F. et al.Aortic arch reconstructive surgery with conventional techniques vs frozen elephant trunk: a systematic review and meta-analysis.Can J Cardiol. 2018; 34: 262-273Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 13Svensson L.G. Crawford E.S. Hess K.R. Coselli J.S. Raskin S. Shenaq S.A. et al.Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients.J Thorac Cardiovasc Surg. 1993; 106: 19-28Abstract Full Text PDF PubMed Google Scholar, 14Svensson L.G. Protecting the brain and spinal cord in aortic arch surgery.Ann Cardiothorac Surg. 2018; 7: 345-350Crossref PubMed Scopus (6) Google Scholar Type A aortic dissection typically originates from a single tear in the ascending aorta (2 cm above the sinotubular junction) but may originate in arch or distal aorta (ie, the descending thoracic, thoracoabdominal, or abdominal aorta) and extend aortopathy in a retrograde fashion.2Coselli J.S. Green S.Y. Aortic arch repair today: open repair is best for most arch lesions.J Cardiovasc Surg (Torino). 2015; 56: 531-546PubMed Google Scholar Of uncertain frequency, the careful assessment of high-quality imaging studies may indicate the presence of multiple tears in extensive type A aortic dissection (ie, DeBakey type I aortic dissection). The article by Tan and colleagues15Tan L. Xiao J. Zhou X. Shen K. Li F. Luo J. et al.Untreated distal intimal tears may be associated with paraplegia after total arch replacement and frozen elephant trunk treatment of acute Stanford type A aortic dissection.J Thorac Cardiovasc Surg. 2019; 158: 343-350.e1Abstract Full Text Full Text PDF Scopus (11) Google Scholar shares insight into the development of postoperative paraplegia after total aortic arch replacement using a frozen elephant trunk extension in the setting of extensive acute type A aortic dissection. The authors reviewed clinical and imaging findings regarding 110 patients to explore contemporary mechanisms of early postoperative paraplegia, which occurred in 5 patients (4.5%). Notably, the stent-graft portion of repair did not extend beyond the T8 vertebra in any of the 110 patients. In the 5 patients with postoperative paraplegia, a “cutoff phenomena” (comprising a greatly narrowed section of the true lumen, a long section of thrombosis in the false lumen that exceeded 2-vertebra in length, and the absence of contrast medium in the false lumen) was observed in 4 patients via computed tomographic imaging studies. Further, they found that the “cutoff phenomena” was related to the nearby presence of downstream re-entry tears within the untreated distal aorta beyond the 12-cm length of the stent-graft. Although these re-entry tears were present in most patients (64%), it was only when they occurred within 30 to 60 mm of the stent-graft that the risk of paraplegia increased. Additionally, the authors noted that 3 of 5 patients with postoperative paraplegia died within 30 days of repair, and the remaining 2 patients had partial recovery of function after the use of cerebrospinal fluid drainage as a rescue measure. Without doubt, the use of the frozen elephant trunk approach is a valuable addition to the surgeon's armamentarium in the treatment of acute type A aortic dissection.11Shrestha M. Bachet J. Bavaria J. Carrel T.P. De Paulis R. Di Bartolomeo R. et al.Current status and recommendations for use of the frozen elephant trunk technique: a position paper by the vascular domain of EACTS.Eur J Cardiothorac Surg. 2015; 47: 759-769Crossref PubMed Scopus (215) Google Scholar, 16Ma W.G. Zheng J. Zhang W. Sun K. Ziganshin B.A. Wang L.F. et al.Frozen elephant trunk with total arch replacement for type A aortic dissections: does acuity affect operative mortality?.J Thorac Cardiovasc Surg. 2014; 148: 963-970Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 17Shrestha M. Haverich A. Martens A. Total aortic arch replacement with the frozen elephant trunk procedure in acute DeBakey type I aortic dissections.Eur J Cardiothorac Surg. 2017; 51: i29-i34Crossref PubMed Scopus (69) Google Scholar However, the use of such novel approaches to aortic arch repair tends to increase the risk of postoperative paraplegia in a repair with minimal historical risk of spinal cord deficit.2Coselli J.S. Green S.Y. Aortic arch repair today: open repair is best for most arch lesions.J Cardiovasc Surg (Torino). 2015; 56: 531-546PubMed Google Scholar, 4Di Bartolomeo R. Murana G. Di Marco L. Pantaleo A. Alfonsi J. Leone A. et al.Frozen versus conventional elephant trunk technique: application in clinical practice.Eur J Cardiothorac Surg. 2017; 51: i20-i28Crossref PubMed Scopus (64) Google Scholar, 5Hanif H. Dubois L. Ouzounian M. Peterson M.D. El-Hamamsy I. Dagenais F. et al.Aortic arch reconstructive surgery with conventional techniques vs frozen elephant trunk: a systematic review and meta-analysis.Can J Cardiol. 2018; 34: 262-273Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 12Kozlov B.N. Panfilov D.S. Ponomarenko I.V. Miroshnichenko A.G. Nenakhova A.A. Maksimov A.I. et al.The risk of spinal cord injury during the frozen elephant trunk procedure in acute aortic dissection.Interact Cardiovasc Thorac Surg. 2018; 26: 972-976Crossref PubMed Scopus (16) Google Scholar, 14Svensson L.G. Protecting the brain and spinal cord in aortic arch surgery.Ann Cardiothorac Surg. 2018; 7: 345-350Crossref PubMed Scopus (6) Google Scholar The authors are to be commended for the investigation of related risk factors pertaining to multiple distal entry tears as well as compression of the true lumen and thrombosis of the false lumen—or the “cutoff phenomena” as the authors term it.15Tan L. Xiao J. Zhou X. Shen K. Li F. Luo J. et al.Untreated distal intimal tears may be associated with paraplegia after total arch replacement and frozen elephant trunk treatment of acute Stanford type A aortic dissection.J Thorac Cardiovasc Surg. 2019; 158: 343-350.e1Abstract Full Text Full Text PDF Scopus (11) Google Scholar Untreated distal intimal tears may be associated with paraplegia after total arch replacement and frozen elephant trunk treatment of acute Stanford type A aortic dissectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 158Issue 2PreviewTo investigate the possible overlooked causes of early postoperative paraplegia, a severe complication of acute Stanford type A aortic dissection (ATAAD) after total arch replacement and frozen elephant trunk (FET). Full-Text PDF Open Archive