The frozen elephant trunk (FET) technique has become a cornerstone in the management of complex aortic arch disease, yet reinterventions, both proximally on the root and distally on the thoracoabdominal aorta, remain common. Conventional FET prostheses were designed to recreate standard arch anatomy with the distal anastomosis beyond the left subclavian artery (LSA) and the supra-aortic branches in proximal-to-distal sequence. However, the current trend towards more proximal anastomosis in zones 0-2, brings the arch branches closer to the aortic root, which can limit root access during reoperation by reducing the available clamping zone, and also creates unfavorable angulations for antegrade visceral vessel cannulation during distal endovascular repair. Here, we describe the step-by-step operative technique for a new graft, the T-NEXT, a customized modification of the Thoraflex hybrid prosthesis, designed for improved life-time management of complex aortic disease, featuring a transverse and distal alignment of the arch branches. This configuration leaves an unobstructed proximal graft segment to facilitate safe distal clamping in future proximal reoperations, while preserving a smooth, bidirectional pathway for antegrade and retrograde endovascular access.

Aortic arch surgery is associated with substantial perioperative risks. New techniques and novel prostheses have been developed to reduce the risks of these procedures. The application of these new techniques has helped to reduce the perioperative risk factors of aortic arch repair. From a technical standpoint, the supra-aortic vessel anastomoses, especially those to the left subclavian artery, can sometimes be technically challenging, resulting in the need for longer circulatory arrest. Therefore, various techniques and devices have been developed in recent years to simplify the supra-aortic vessel anastomosis. A new hybrid graft to simplify the supra-aortic vessel anastomosis during total arch replacement is described.

The frozen elephant trunk (FET) provides single-stage repair of complex, concomitant aortic arch and descending aortic disease, integrating both conventional and endovascular approaches. While multiple meta-analyses affirm short-term safety, long-term outcomes remain largely unknown, especially regarding overall survival and freedom from re-intervention. This current systematic review and meta-analysis aims to summarize the short- and long-term outcomes following the use of FET in aortic pathology.

The frozen elephant trunk (FET) technique has revolutionized the surgical management of aortic dissection. However, distal stent-graft-induced new entry (dSINE) and reinterventions remain major challenges. This study presents the long-term results of a dissection-specific (DS) "Soft Elephant Trunk" (SET) (MedEng, Penza, Russia) hybrid prosthesis and its impact on distal remodeling compared to conventional hybrid prosthesis.

The Sun procedure has been widely adopted across China for the treatment of acute type A aortic dissection (ATAAD). Although favorable outcomes have been reported from high-volume centers, institutional series offering detailed early data using modern operative protocols remain limited. This study is structured in two parts: first, a review of the literature on the development and reported outcomes of the Sun procedure in different aortic populations across China; and second a presentation of contemporary operative characteristics and early outcomes in patients undergoing the Sun procedure for ATAAD at a single institution.

The frozen elephant trunk (FET) technique is a well-established procedure for chronic and acute aortic arch (AA) pathologies. Over time, practice has shifted from deep to moderate hypothermic circulatory arrest (HCA), especially for elective cases. This strategy might, however, impact neurological and renal outcomes. The aim of this single-center study is to assess the safety of very mild HCA (MiHCA) in patients who underwent FET with a core temperature ≥30 ℃.

The frozen elephant trunk (FET) technique represents a significant advancement in the surgical management of complex aortic pathologies involving the aortic arch and descending thoracic aorta. This review traces the evolution of the FET procedure from its conceptual origins in the conventional elephant trunk (ET) technique to its current application as a hybrid, single-stage intervention. The FET technique integrates open surgical repair with endovascular technology, allowing for simultaneous aortic arch replacement and stent-graft deployment into the descending aorta. Key indications include acute and chronic aortic dissections, arch aneurysms, and malperfusion syndromes. Surgical considerations such as cannulation strategy, cerebral protection, and spinal cord preservation are discussed in detail, with emphasis on techniques that enhance safety and outcomes. The development of commercially available FET prostheses-such as E-vita Open Neo, Thoraflex Hybrid, and Frozenix-has improved procedural versatility and enabled individualized treatment strategies. Innovations in graft design, including proximalization of distal anastomosis and integration of side branches, have further simplified the procedure and broadened its applicability. Despite variability in outcomes across patient populations, the FET procedure is associated with favorable early and mid-term results, including reduced inter-stage mortality and enhanced aortic remodeling. The technique continues to evolve, driven by advances in device technology and a growing emphasis on tailored, patient-specific surgical approaches.

Aortic arch surgery has evolved significantly with novel techniques aimed at reducing morbidity and mortality. Traditional approaches rely on hypothermic circulatory arrest (HCA), which remains associated with neurological and systemic complications. This study presents our initial experience with a normothermic frozen elephant trunk (FET) technique that eliminates circulatory arrest while maintaining continuous cerebral and systemic perfusion.

The evolution of surgical replacement of the aortic arch has been shaped by advances in surgical techniques and ancillary technologies. From the early pioneering attempts in the 1950s by Ho Ju Lin, Cooley, and DeBakey, which preceded the advent of cardiopulmonary bypass (CPB), the development of perfusion, cerebral protection, and surgical techniques, along with the evolution of prosthetic grafts, has progressively enabled surgeons to address these challenging conditions with greater confidence. Despite these remarkable advancements, aortic arch surgery still remains one of the most technically challenging procedures in cardiac surgery. A major turning point was the introduction of the elephant trunk technique by Borst in 1983. This approach allowed for staged treatment of diffuse aneurysmal disease, including both degenerative and post-dissection cases, and reduced the overall surgical risk across multiple procedures. Initially met with skepticism, the technique has since been universally adopted by centers specializing in aortic pathology. At the same time, numerous modifications to the technique have emerged. Each modification has addressed specific technical challenges or enabled the integration of new technologies. The development of the Siena graft in the early 2000s was driven by the need to harness the growing potential of endovascular devices, which had been evolving since the 1990s, and to address critical technical issues. These included the use of multi-branched prostheses and the introduction of an anastomotic collar to facilitate secure distal anastomoses, even in less-than-ideal anatomical conditions. The design of the Siena graft, now widely adopted by most manufacturers for arch grafts, required close collaboration with industry partners to ensure a reliable product from its inception. Today, the Siena graft remains a highly relevant platform for the treatment of diffuse aneurysmal disease that requires the elephant trunk technique. This paper describes the evolution and design of the graft, the technical approach, including pitfalls and safeguards, and our clinical experience.

Marfan syndrome (MFS) is a connective tissue disease which can lead to aortic aneurysm and dissection. The performance outcomes of total aortic arch replacement with frozen elephant trunk (FET) are not well known in these patients. This study summarizes our experience with FET in MFS.

At first glance, the frozen elephant trunk (FET) appears as a disruptive innovation in aortic surgery. Like any important surgical innovations, however, be it a product or a procedure, the prefabricated, four-branched device has undergone a stepwise, iterative phase of development prior to its first clinical implantation in 2010. In parallel, the surgical procedure of aortic arch replacement itself has had to mature towards a level of quality and risk control to allow for refinement via a new device. These preparatory technical steps included mastering circulatory arrest, including brain and spinal cord protection, which required decisive innovation in extracorporeal circulation (ECC) management. In addition, patient selection with respect to age and risk factors, but also his or her underlying disease-aneurysm, dissection, atherosclerosis-has been optimized prior to the introduction of the prefabricated substitute for aortic arch replacement. Of utmost importance were those steps, taken by individual surgeons and institutions by use of self-fabricated substitutes, combining various commercially available devices. Thus, the frozen elephant technique, as applied today, did not crash into the armamentarium of unprepared aortic surgeons via device engineering and industrial product development alone. Instead, it resembles an evolutionary process, guided by a number of international institutions exploring preliminary approaches, and learning from each other via scientific exchange. This process, however, would have remained unthinkable without the tremendous advances in medical imaging via tomographic techniques, including their increasing resolution and 3D depiction. This communication will focus on the intermediary surgical steps and the technological advances between the prefabrication of the FET by the medical product industry and its first successful clinical application, as it is used today.

The frozen elephant trunk (fET) has become the preeminent choice for aortic arch repair with easier second-stage endovascular solutions compared to the conventional elephant trunk (cET). Traditionally, the major advantage of cET implantation is reduced risk of spinal cord injury (SCI). With increased rates of implantation and refinement in technique, we aim to investigate if previous adverse events of fET, such as SCI, have been reduced to a level comparable to the cET.

After the US Food and Drug Administration (FDA) approved the Thoraflex Hybrid device in April 2022, hybrid devices to facilitate total arch replacement (TAR) became commercially available in the United States. However, little is known about how the Thoraflex device has been used since then. We present our experience (2016-2025) with this device.