Aortic Arch and Frozen Elephant Trunk Surgery: Anesthetic Challenges and Strategies for Organ Protection

Background: Aortic arch surgery using the frozen elephant trunk (FET) technique remains one of the most complex scenarios in cardiac anesthesia. The anesthesiologist plays a central role in maintaining neuroprotection, organ perfusion and hemodynamic stability during hypothermic circulatory arrest and selective cerebral perfusion. This review summarizes key anesthetic principles aimed at improving neurologic and systemic outcomes. Methods: This narrative review examines current evidence and expert recommendation on temperature and perfusion management, neuromonitoring, coagulation control and postoperative strategies specific to FET procedures. Results: Modern approaches emphasize moderate hypothermia with tailored selective cerebral perfusion, multimodal neuromonitoring and structured organ protection bundles. Evidence supports the use of physiology-guided perfusion, viscoelastic-based coagulation management and coordinated teamwork with surgical and perfusion specialists to reduce neurologic injury, bleeding and postoperative organ dysfunction. Conclusions: Anesthetic management in FET surgery requires an integrated, physiology-based strategy supported by advanced monitoring and close interdisciplinary coordination. Adoption of standardized organ-protection and perfusion protocols is essential to optimize neurologic and systemic outcomes in this high-risk population.