Frozen elephant trunk: Approach and innovations from the UK's leading centre.

The frozen elephant trunk (FET) procedure has emerged as a transformative approach for complex aortic arch pathology, addressing limitations of conventional elephant trunk procedures, including the need for second-stage operations with interval mortality, inability to expand the true lumen in dissections and lack of distal anastomotic support.Our experience with over 200 procedures demonstrates FET technique evolution and refinement, achieving 13.8% overall mortality. Presenting pathologies were diverse, predominantly aneurysmal disease and acute or chronic dissections. Most utilised Thoraflex Hybrid, though the Jotec E-vita prosthesis has been increasingly used recently. Critical technical advancements include bilateral axillary artery cannulation, which has dramatically reduced neurological complications, including paraplegia and recurrent laryngeal nerve injury, compared to historical series. It also made the procedure technically less complex and more reproducible. In selected cases, we have also adopted a beating heart strategy to reduce the cardiac ischaemic time once the proximal aortic repair has been completed. The beating heart strategy demonstrated a tendency for reduced post-operative adrenaline requirements without compromising outcomes.Frozen elephant trunk demands advanced perfusion strategies, proactive spinal cord protection and meticulous surgical technique but reduces the need for future open repair, facilitating endovascular interventions. Our experience demonstrates that FET represents a paradigm shift toward comprehensive single-stage treatment of complex aortic arch pathology with acceptable outcomes when performed in high-volume centres by experienced multidisciplinary teams.