＜Editors' Choice＞ Which is superior, the frozen elephant trunk technique alone or the classical elephant trunk technique followed by second-stage thoracic endovascular aortic repair for extensive aortic arch repair?

Paraplegia is one of the most devastating complications during extensive aortic arch repair. We retrospectively analyzed our results by comparing primary repair using the frozen elephant trunk technique (FET) and the classical elephant trunk technique (CET) followed by second-stage thoracic endovascular aortic repair (TEVAR), which has been performed since 2009. Between March 1997 and September 2015, 91 patients (the mean age: 70 ± 8.6 years old, 73 men and 18 women) underwent total aortic arch replacement with either the FET (54 cases) or CET (37 cases). The CET was followed by second-stage TEVAR with a median duration of 36 days. The number of in-hospital deaths was 2 (3.7%) in FET and none in CET. The overall survival was 73% in FET and 83% in CET at 5 years with no significant difference (p=0.73). Aortic events occurred in 12 cases (22%) in FET and 3 (8%) in CET. The rate of freedom from aortic events was 77% in FET and 91% in CET at 5 years with no significant difference (p=0.45). Five neurologic events (9%) occurred after the FET, and 3 events (8%) occurred after the CET (p=0.85). No patients in the CET group experienced paraplegia, while the FET group showed a relatively high paraplegia rate (17%, p=0.014).The FET with primary repair for extensive aortic arch repair had an acceptable hospital mortality rate and aortic events but was associated with a high incidence of paraplegia. The CET followed by second-stage TEVAR achieved better early results with a low risk of paraplegia and may produce a favorable mid-term surgical outcome for extensive aortic arch repair.