Normothermic frozen elephant trunk surgery without circulatory arrest: is this the future?

Frozen elephant trunk (FET) repair has expanded the treatment of complex aortic arch pathology but continues to rely on hypothermic circulatory arrest (HCA), which remains a major physiological limitation of the procedure. In this Keynote, we describe our current normothermic FET strategy, designed to perform arch reconstruction under continuous cerebral and systemic perfusion, through the integration of open and endovascular techniques. Retrograde stent-graft deployment and balloon occlusion within the prosthesis allow controlled distal aortic clamping while maintaining uninterrupted systemic circulation. In our initial experience, the technique was technically feasible and associated with acceptable perioperative hemodynamic and metabolic profiles; however, given the limited clinical experience, these findings should be interpreted as preliminary and require further evaluation. Beyond its technical aspects, this approach reflects a conceptual shift in arch surgery from mitigating the consequences of circulatory arrest to pursuing strategies aimed at avoiding it. In selected patients, normothermic FET may represent a physiologically oriented option within the ongoing evolution of contemporary aortic arch repair.