Do early aortic remodeling patterns at 6 months predict mid-term outcomes after frozen elephant trunk for chronic aortic dissection?

OBJECTIVES To determine whether computed tomography (CT) within 6 months after total arch replacement with a frozen elephant trunk (FET) for chronic aortic dissection predicts mid-term outcomes and informs the timing of distal treatment. METHODS We analyzed 56 consecutive patients who underwent total arch replacement with FET at two centers (2009–2022) and had evaluable 6-month postoperative CT. Early remodelling was defined as the change from baseline to 6 months in the maximal outer-to-outer diameter of the proximal descending thoracic aorta at Level A (Ishimaru zone 3, 20 mm distal to the left subclavian artery, measured on centerline-orthogonal reconstructions). Patients were classified as early positive remodelling (EPR; no increase or a decrease) or early negative remodelling (ENR; ≥1-mm increase). Prespecified outcomes were distal aortic reintervention, distal stent graft–induced new entry (dSINE), and overall survival. RESULTS Mean follow-up was 5.4 years (standard deviation 3.7). Distal reintervention was required in 36/56 patients (64%). At 5 years, freedom from distal reintervention was higher with EPR than with ENR (44.6% vs 6.2%; p = 0.003). dSINE occurred in 26/56 patients (46.4%); 5-year dSINE-free survival was 65.1% (95% confidence interval [CI], 39.6–81.9) with EPR versus 18.2% (95% CI, 5.9–35.2) with ENR (p = 0.008). Overall, 5-year survival for the cohort was 80.0% (95% CI, 64.7–89.2). Among ENR patients, 5-year survival was 0% with conservative management versus 40.5% with distal intervention (p < 0.001); within EPR, 5-year survival was 65.9% with conservative management versus 85.7% with reintervention (p = 0.210). CONCLUSIONS A 6-month CT provides simple, actionable risk stratification after total arch replacement with FET for chronic aortic dissection. Absence of EPR identifies a high-risk subgroup (ENR) that warrants closer surveillance and timely distal intervention, optimizing follow-up intensity and treatment timing.