Introduction

The introduction of hybrid arch repair techniques as an alternative to purely open approaches has greatly facilitated the management of aortic arch and proximal descending thoracic aortic disease. Surgery on these aortic segments is challenging to address through either a sternotomy or thoracotomy alone, and so was traditionally often tackled in separate stages. In 1983, Borst et al. introduced the elephant trunk (ET) technique, where through a median sternotomy, a 10-cm section of Dacron graft is left distal to the site of distal anastomosis in the arch.¹ The second stage is then carried out through the left chest where the proximal anastomosis is now simplified by the ET. Inter-stage mortality remains a concern with this approach.^2,3

The frozen elephant trunk (FET) procedure was first described by Kato et al. in 1996, and it evolved through adoption of thoracic endovascular aortic repair (TEVAR) techniques.⁴ Stent-graft technology has been a revolutionary advance, converting surgeries with large morbid incisions into minimal-access procedures. Having a stent-supported ET affords several benefits that we will review, including the optimization of subsequent aortic interventions in the contemporary era of endovascular intervention, and elimination of the second-stage repair in some patients. It has also been an important addition to the armamentarium in the treatment of acute type A dissections.^5,6

Endovascular arch repair that avoids cardiopulmonary bypass and a median sternotomy altogether remains fraught with stroke risk and technical challenges related to arch angulations and inadequate proximal fixation. These techniques are in fact usually hybrid in that they tend to incorporate varying degrees of open arch vessel debranching. New developments in this area and a comparison of various hybrid arch techniques are explored.

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