Hybrid Pin Penetration Open Stent Technique: Retrospective Study of a New Approach to Frozen Elephant Trunk Procedure

Total arch replacement using the frozen elephant trunk (FET) technique for acute Type A aortic dissection involving the aortic arch remains technically demanding because of complex supra-aortic branch reconstruction and prolonged circulatory arrest. We developed a modified fenestrated open stent technique, termed the hybrid pin-penetration open stent technique (HIPPOS), to simplify branch reconstruction while minimizing supra-aortic vessel manipulation. We retrospectively reviewed 15 consecutive patients who underwent total arch replacement using HIPPOS between May 2024 and May 2026 at a single institution by a single surgeon. Following deployment of a Frozenix open stent graft, antegrade fenestrations were created under direct vision using needle penetration and sequential dilation, followed by reconstruction with balloon-expandable covered stent grafts. All procedures were successfully completed. Operative durations decreased with increasing numbers of fenestrations, reflecting procedural refinement and the surgical learning curve. Two perioperative deaths occurred in patients with profound preoperative shock, and one patient experienced a non-disabling stroke. No postoperative hoarseness, paraplegia, fenestration-related endoleak, or distal stent-induced new entry was observed. Follow-up computed tomography angiography confirmed satisfactory graft conformability and durable branch patency. HIPPOS is a reproducible modification of the FET procedure with encouraging early clinical outcomes.