Aortic arch surgery in real-life practice: is the frozen elephant trunk always a better option than conventional...

Management of aortic arch disease (AAD) is complex due to its involvement in multiple aortic segments and the variety of patient presentations. We compared the clinical outcomes of conventional aortic arch repair (CAAR) and the Frozen Elephant Trunk (FET) technique across the main clinical indications: acute type A aortic dissection (ATAAD), chronic dissection and atheromatous aneurysm.

We conducted a retrospective, single-centre cohort study of 102 consecutive patients who underwent aortic arch repair between January 2012 and June 2023. Indication-specific subgroup analyses were the primary analytical framework. Patients were divided according to the surgical technique: CAAR (n = 45, 44.1%) or FET (n = 57, 55.9%). Pre- and post-operative CT-angiograms were analysed. The primary endpoint was one-year survival. Secondary endpoints included post-operative morbidity, aortic diameter evolution, and freedom from a composite aortic event. Time-to-event endpoints were estimated by the Kaplan-Meier method and compared with the log-rank test.

One-year mortality was 27.5% (CAAR 28.9% vs. FET 26.3%; not statistically different in indication-specific subgroups). Mortality was driven by ATAAD (35.4%) and chronic dissection (30.8%); it was 4.2% in atheromatous aneurysm. In ATAAD, FET was associated with favourable aortic remodelling, with a 24.3% reduction in isthmus diameter compared with a 25.8% increase after CAAR (p = 0.0005). In chronic dissection, FET resulted in a 13.6% reduction in isthmus diameter at follow-up. In aneurysmal disease, FET stabilised aortic diameters whereas CAAR was associated with a 20.8% increase in isthmus diameter (p < 0.05). Reinterventions were more frequent after FET (42.1% vs. 17.8%); the great majority were planned staged TEVAR extensions.

In experienced centres, the FET technique appears safe and is associated with favourable aortic remodelling. It represents a valuable option when downstream aortic disease or future endovascular extension is anticipated. Given the non-randomised design and indication imbalance, our data do not support a definitive claim of superiority over CAAR. Surgical strategy should remain anatomy- and indication-driven within a lifetime aortic management framework.