From back table innovation to contemporary application: a review of the frozen elephant trunk technique

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.