BackgroundThe introduction of the frozen elephant trunk (FET) technique for total arch replacement (TAR) has revolutionized the field of aortivascular surgery by allowing hybrid repair of complex aortic pathologies in a single step through combining an open surgical approach with an endovascular one. FET has been associated with favorable aortic remodeling, however, its is also associated with development of distal stent graft induced new entry (dSINE) tears postoperatively. The rate of aortic remodeling and the incidence of dSINE have been linked together, in addition, there seems to be a relationship between these two variables and FET insetion length as well as graft size.AimsThe scope of this review is to highlight the rate of aortic remodeling as well the incidence of dSINE associated with different FET devices available commercially. This review also aimed to investigate the relationship between aortic remodeling, dSINE, FET insertion length and FET graft size.MethodsWe conducted a comprehensive literature search using multiple electronic databases including PubMed, Ovid, Scopus and Embase in order to collate all research evidence on the above mentioned variables.ResultsThoraflex™ Hybrid Plexus seems to yield optimum aortic remodeling by promoting maximum false thrombosis as well true lumen expansion. Thoraflex Hybrid™ is also associated with the lowest incidence of dSINE post-FET relative to the other FET devices on the market. Aortic remodeling and dSINE do influence each other and are both linked with FET graft length and size.ConclusionThe FET technique for TAR shows excellent aortic remodeling but is associated with a considerable risk of dSINE development. However, Thoraflex™ Hybrid has demonstrated itself to be the superior FET device on the aortic arch prostheses market. Since aortic remodeling, dSINE, FET insertion length and stent graft size are all interconnect, the choice of FET device length and size must be made with great care for optimum results.

Background and Aim of the Study The frozen elephant trunk (FET) procedure became a popular entity for utilization in aortic arch aneurysm disease. However, its proper mortality and morbidities as well as the predictors of outcomes are poorly identified. This systematic review and meta‐analysis explore FET outcomes and its predictors with a focus on zone aortic proximalization. Methods We searched PubMed/MEDLINE, EMBASE, and Scopus databases from their beginning to June 2020 to find studies reporting the outcomes of the FET procedure for the total arch replacement (TAR). Results A total of 64 studies including 7967 patients were evaluated. The pooled estimates of cerebrovascular accidents, paraplegia, renal failure, and in‐hospital mortality were 7.104 (95% confidence interval [CI], 5.691–8.661; I2 = 78.53%), 3.465 (95% CI, 2.852–4.136; I2 = 15.96), 14.969 (95% CI, 11.361–18.977; I2 = 91.26%), and 8.933 (95% CI, 7.128–10.919; I2 = 78.51%), respectively. Stratification by the geographical locations and by the aortic pathologies led to lower heterogeneity, but not for renal failure. The distal anastomosis in Zone 2 was associated with a lower rate of renal failure compared with Zone 3 (odds ratio, 0.54; 95% CI, 0.36–0.81; p = .003; I2 = 0%). Conclusions The FET procedure for TAR can be performed with acceptable mortality and morbidities among patients with complex aortic pathologies. Moreover, the distal anastomosis in Zone 2 was associated with lower renal failure compared to Zone 3.

Background The treatment of complex thoracic aorta pathologies remains a challenge for cardiovascular surgeons. After introducing Frozen Elephant Trunk (FET), a significant evolution of surgical techniques has been achieved. The present meta‐analysis aimed to assess the efficacy of FET in acute type A aortic dissection (ATAAD) and the effect of circulatory arrest time on post‐operative neurologic outcomes. Methods A standard Preferred Reporting Items for Systematic Reviews and Meta‐Analyses search was conducted for all observational studies of patients diagnosed with ATAAD undergoing total arch replacement with FET reporting in‐hospital mortality, bleeding, and neurological outcomes. A random‐effect meta‐analysis was performed using STATA software (StataCorp, TX, USA). Results Thirty‐five studies were eligible for the present meta‐analysis, including 3211 patients with ATAAD who underwent total arch replacement with FET. The pooled estimate for in‐hospital mortality, postoperative stroke, and spinal cord injury were 7% (95% CI 5 – 9; I2 = 68.65%), 5% (95% CI 4 – 7; I2 = 63.93%), and 3% (95% CI 2 – 4; I2 = 19.56%), respectively. Univariate meta‐regression revealed that with increasing the duration of hypothermic circulatory arrest time, the effect sizes for postoperative stroke and SCI enhances. Conclusions It seems that employing the FET procedure for acute type A dissection is associated with acceptable neurologic outcomes and a similar mortality rate comparing with other aorta pathologies. Besides, increasing hypothermic circulation arrest time appears to be a significant predictor of adverse neurologic outcomes after FET.