Distal repair after frozen elephant trunk: open or endovascular?

The frozen elephant trunk (FET) technique has grown in popularity as an effective therapy for aortic arch and descending thoracic aorta pathologies. In particular, many experienced aortic centers have become more aggressive by employing a total arch replacement with FET in the setting of aortic dissection. As a single stage option, the FET stent-graft can be used to cover proximal entry tears in the descending aorta with the goal of inducing false lumen thrombosis and promoting favorable aortic remodeling. If this single stage goal is not achieved, the endograft nonetheless remains a suitable proximal platform onto which a subsequent endovascular or open procedure may be performed when distal reintervention is necessary. Distal aortic reinterventions following FET are common: Kreibich and colleagues demonstrated a 33% reintervention rate following FET. Common reasons for reintervention included aneurysmal dilation of the descending aorta, endoleak and stent graft-induced new entry tear (SINE) (1). It should be noted that reintervention rate alone is an insufficient measure to judge whether a proximal index operation is successful; ideally a composite of index operation failure, which includes: aortic-related death, unplanned reintervention and aneurysmal diameter >6 cm, is the metric that should be used to determine the distal success of index procedures. © Annals of Cardiothoracic Surgery. All rights reserved