Introduction
Both acute and chronic aortic pathologies are often associated with descending aorta disease. The Frozen Elephant Trunk (FET) hybrid procedure has developed to treat both segments, sometimes with a definitive aortic reconstruction in one stage or in anticipation of subsequent completion with thoracic endovascular repair (TEVAR). Thoraflex™ Hybrid (Terumo Aortic) is a dedicated FET device that joins a distal endovascular nitinol ringed stent-graft with a proximal 4-branched surgical graft and has been used in acute and chronic settings to reduce circulatory arrest time and improve cerebral and systemic perfusion.1 We have implanted over 70 Thoraflex Hybrid devices and been challenged by reimplantation of the supra-aortic trunk (SAT) vessels, expecially the left carotid (LCA) and left subclavian (LSA) arteries, their chest positioning, and management of cerebral perfusion. To address this, we requested a custom-made configuration and describe here the first experience.