Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic surgery (EACTS) and the European Society for Vascular Surgery (ESVS).

The implementation of new surgical techniques offers chances but carries risks. Usually, several years pass before a critical appraisal and a balanced opinion of a new treatment method are available and rely on the evidence from the literature and expert's opinion. The frozen elephant trunk (FET) technique has been increasingly used to treat complex pathologies of the aortic arch and the descending aorta, but there still is an ongoing discussion within the surgical community about the optimal indications. This paper represents a common effort of the Vascular Domain of EACTS together with several surgeons with particular expertise in aortic surgery, and summarizes the current knowledge and the state of the art about the FET technique. The majority of the information about the FET technique has been extracted from 97 focused publications already available in the PubMed database (cohort studies, case reports, reviews, small series, meta-analyses and best evidence topics) published in English.

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Implantation of the EDWARDS INTUITY Valve System is feasible, safe, and efficacious for aortic valve replacement. Aortic crossclamp and cardiopulmonary bypass times were reduced compared with those for conventional aortic valve replacement. Early hemodynamic performance was excellent and remained so up to 1 year.

This European multicentre experience, with the largest cohort of patients with sutureless valves to date, shows excellent clinical and haemodynamic results that remain stable even up to the 5-year follow-up. Even in this elderly patient cohort with 40% octogenarians, both early and late mortality rates were very low. There were no valve migrations, structural valve degeneration or valve thrombosis in the follow-up. The sutureless technique is a promising alternative to biological aortic valve replacement.

Moderate hypothermic circulatory arrest in combination with cold selective antegrade cerebral perfusion is an adequate tool for neuroprotection during aortic surgery. Nevertheless, the safety of this technique is limited for patients with long intraoperative durations, advanced age, and multiple comorbidities. This technique, which avoids profound core temperatures, has become an alternative to simple deep hypothermic circulatory arrest.

FET results are comparable with those of the published results of the conventional elephant trunk technique. FET is an ideal landing zone for subsequent transfemoral endovascular completion. Patients with graft infections may have dismal results.

The Thoraflex Hybrid graft adds to the frozen elephant trunk concept for treating aortic arch and descending aortic disease. Implantation of the Thoraflex Hybrid graft resulted in excellent outcomes and beneficial aortic remodeling during follow-up. This graft increases surgeons' armamentarium in the treatment of complex and diverse aortic arch pathology.