Frozen elephant trunk (FET) has in recent times become a mainstay for total arch replacement (TAR) in aortovascular surgery and is indicated in order to treat a spectrum of complex aortic pathologies. However, despite associated excellent post-operative results it is incredibly important to recognise potential adverse complications such as negative aortic remodelling, endoleak and distal stent-graft induced new entry so that outcomes can be further improved. Below we provide commentary on a recent article in the Journal of Cardiac Surgery discussing the topic. Despite the fascinating outcomes of this systematic review and meta-analysis the heterogeneity of the literature regarding these adverse outcomes remains an issue which can only be solved with large multi-centre trials directly comparing graft types as well as indications for surgery.

Thoracic endovascular aortic repair (TEVAR) has quickly become the mainstay of treatment for acute aortic dissection, in particular cases of acute complicated Stanford Type B dissection (co-TBAD). Necessarily, TEVAR carries with it the risk of postoperative complications, including stroke and renal failure. As a result, the management of patients with uncomplicated type B aortic dissection (un-TBAD), which is generally accepted as being less severe, are safely managed via optimal medical therapy (OMT) alone. However, despite OMT, patients with un-TBAD are at substantial risk of severe disease progression requiring delayed intervention. The cost-benefit ratio associated with TEVAR for un-TBAD is therefore of key interest. Howard and colleagues produced a fascinating systematic review and meta-analysis investigating the clinical outcomes of TEVAR for complicated and uncomplicated TBAD. Their data suggests that there is no significant difference in in-hospital mortality or 5-year survival between TEVAR for un-TBAD and co-TBAD, although the 30-day mortality rate appeared to be higher in the co-TBAD cohort. Patients with co-TBAD appeared to also be at a higher risk of postoperative stroke and TEVAR endoleak, while un-TBAD patients were at a higher risk of postoperative renal failure. Further prospective research into these relationships are recommended to fully elucidate the comparative efficacies of TEVAR for un-TBAD and co-TBAD.

Total arch repair (TAR) has become a mainstay of the surgical management of complex pathologies of the ascending aorta and aortic arch, in particular acute Type A aortic dissections (ATAAD). TAR with devices such as the frozen elephant trunk (FET) have been shown to dramatically improve clinical outcomes in such cases. However, TAR with FET remains an immensely challenging procedure, and the risk of debilitating postoperative complications remains high. Spinal cord ischaemia (SCI) and stroke are two particularly tragic adverse outcomes of TAR with FET; it is unsurprising therefore that much research has been done to determine both the underlying cause thereof, and strategies to mitigate this risk. Mousavizadeh and colleagues produced a fascinating systematic review and meta-analysis investigating the relationship between the duration of hypothermic circulatory arrest (HCA) and the risk of developing complications including SCI and stroke. Their data seem to suggest HCA duration is a key factor in causing SCI and stroke following TAR with FET for ATAAD. However, other factors such as stent sizing and landing zone also contribute. Further prospective research into this relationship is recommended to fully elucidate what truly is to blame for these postoperative neurological complications.