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Frozen elephant trunk (FET) has in recent times become a mainstay for total arch replacement (TAR) in aortovascular surgery and is indicated in order to treat a spectrum of complex aortic pathologies. However, despite associated excellent post-operative results it is incredibly important to recognise potential adverse complications such as negative aortic remodelling, endoleak and distal stent-graft induced new entry so that outcomes can be further improved. Below we provide commentary on a recent article in the Journal of Cardiac Surgery discussing the topic. Despite the fascinating outcomes of this systematic review and meta-analysis the heterogeneity of the literature regarding these adverse outcomes remains an issue which can only be solved with large multi-centre trials directly comparing graft types as well as indications for surgery.

Introduction: Obesity (body mass index [BMI] >30) and lower limb venous disease (LLVD) is a common problem, yet there is a sparsity of evidence in its management. The aim was to carry out a satisfaction survey on such patients following their venous surgery from a single center. Methods: Three hundred and thirty procedures carried out from January 2017 to April 2018. Eighty-seven patients with BMI > 30 were selected and case notes reviewed retrospectively. Data on demography, risk factors, Clinical, Etiology, Anatomy, Pathology (CEAP) status, operative data, and complications were collected. Fifty-three patients had a telephone follow-up to assess satisfaction in terms of symptoms and appearance. Logistic regression analysis was carried out to identify factors contributing to a worse outcome. Results: The mean age was 53.1 (50.6% were male). The mean BMI was 36.11 (30–56). CEAP grade of more than 3 was present in 69.8% (44/87). Most patients were treated by radiofrequency ablation (81.6% [71/87]). Significant complications occurred in 3.4% (3/87) after surgery. The median follow-up was 22 months (14–30). Symptoms improvement was reported in 74% (39/53), while 5.6% (3/53) reported worse symptoms. In terms of appearance, 71.6% (38/53) reported improvement, while 7.5% (4/53) reported worse appearance. Logistic regression analysis identified BMI to be a significant risk factor (odds ratio 1.257 (95% confidence interval 1.004–1.575). Conclusions: The higher the BMI, the lesser the patient satisfaction after varicose vein surgery. Obese patients with LLVD can be treated successfully with a high satisfaction rate for BMI class 1 and 2.

Uncomplicated Type B aortic dissection (un-TBAD) is still managed conservatively with optimal medical therapy (OMT) despite evidence in favour of thoracic endovascular aortic repair (TEVAR) for un-TBAD. OMT aims to regulate heart rate and blood pressure and patients require long-term follow-up to evaluate the extent of dissection, however, many un-TBAD patients are lost to follow-up. Several trials and observational studies evaluated the use of TEVAR in combination with OMT in un-TBAD and proved the safety, effectiveness, and comparability of TEVAR relative to OMT alone. What remains in question is the optimal time window to intervene with TEVAR. This was recently addressed in a fascinating review by Jubouri et al. AIMS: This commentary aims to discuss the recent review by Jubouri et al. which further proved that TEVAR is safe and effective in un-TABD and investigated the optimal timing of TEVAR in un-TBAD.We carried out a literature search using multiple electronic databases including PUBMED and Scopus in order to collate research evidence on intervention timeframe and outcomes of TEVAR in un-TBAD.Performing TEVAR during the subacute phase of dissection (15-90 days since symptom onset) seems to be associated with less periprocedural complications compared to the acute phase, however, late outcomes (30 days post-TEVAR) are comparable between the two groups and are superior to the chronic phase.The introduction of TEVAR in un-TBAD presents a paradigm shift in the management of un-TBAD and a potential move towards becoming the gold-standard treatment option for un-TBAD. Intervening with TEVAR within the first 90 days since symptom onset (acute and subacute un-TBAD) gives favourable outcomes relative to intervention in the chronic phase of dissection (90 days since symptom onset), this is due to the dissecting septum becoming less compliant over time.TEVAR is a safe and effective treatment modality for un-TBAD with a survival benefit compared to OMT alone. Offering TEVAR during the subacute phase of dissection yields optimal results which are comparable to the acute phase but superior to the chronic phase.

The introduction of the single-step total arch replacement (TAR) with frozen elephant trunk (FET) has revolutionised the field of aortic surgery. TAR is indicated when the aortic arch is involved in aortic pathologies such as Type A aortic dissection and thoracic aortic aneurysms. Several FET devices are available commercially for global use, and example is the E-Vita Open NEO hybrid prosthesis (HP) developed by CryoLife-JOTEC. Unlike other FET devices available, this HP in particular features a design that puts it at a disadvantage as it does not incorporate gelatine or collagen in its structure, which makes it permeable to blood. Several studies have reported incidence of post-anastomotic blood oozing through the E-Vita Open NEO right after weaning from cardiopulmonary bypass.This commentary aims to discuss the recent study by Tan et al. which investigated E-Vita NEO device oozing as well as the implications of using BioGlue to overcome this serious complications.We carried out a literature search on multiple electronic databases including PUBMED and Scopus in order to collate research evidence on E-Vita NEO device oozing, BioGlue health risks, and other commercially available and globally used FET devices such as Thoraflex Hybrid.It is proven fact that the E-Vita NEO excessively oozes blood, and while BioGlue is a safe and effective agent when used in small amounts, the amount needed to coat the E-Vita Open NEO and achieve haemostasis exceeds this by a wide margin which poses patients to great potential health risks. The Thoraflex Hybrid Prosthesis developed by Terumo Aortic is a commercially available and globally used FET device with long-standing favourable outcomes.Tan et al. recently conducted an interesting study which proved that the E-Vita NEO HP does excessively ooze blood and tackled the issue of pre-emptive BioGlue use to tackle this complication as suggested by Ho et al. This leads on to the main question, is the use of BioGlue with E-Vita Open NEO to overcome oozing a long-term sustainable solution or is it merely a band aid?In the face of fierce commercial competition, the choice of design and material of the E-Vita Open NEO HP would benefit from reconsideration.

Thoracic endovascular aortic repair (TEVAR) has quickly become the mainstay of treatment for acute aortic dissection, in particular cases of acute complicated Stanford Type B dissection (co-TBAD). Necessarily, TEVAR carries with it the risk of postoperative complications, including stroke and renal failure. As a result, the management of patients with uncomplicated type B aortic dissection (un-TBAD), which is generally accepted as being less severe, are safely managed via optimal medical therapy (OMT) alone. However, despite OMT, patients with un-TBAD are at substantial risk of severe disease progression requiring delayed intervention. The cost-benefit ratio associated with TEVAR for un-TBAD is therefore of key interest. Howard and colleagues produced a fascinating systematic review and meta-analysis investigating the clinical outcomes of TEVAR for complicated and uncomplicated TBAD. Their data suggests that there is no significant difference in in-hospital mortality or 5-year survival between TEVAR for un-TBAD and co-TBAD, although the 30-day mortality rate appeared to be higher in the co-TBAD cohort. Patients with co-TBAD appeared to also be at a higher risk of postoperative stroke and TEVAR endoleak, while un-TBAD patients were at a higher risk of postoperative renal failure. Further prospective research into these relationships are recommended to fully elucidate the comparative efficacies of TEVAR for un-TBAD and co-TBAD.

Total arch repair (TAR) has become a mainstay of the surgical management of complex pathologies of the ascending aorta and aortic arch, in particular acute Type A aortic dissections (ATAAD). TAR with devices such as the frozen elephant trunk (FET) have been shown to dramatically improve clinical outcomes in such cases. However, TAR with FET remains an immensely challenging procedure, and the risk of debilitating postoperative complications remains high. Spinal cord ischaemia (SCI) and stroke are two particularly tragic adverse outcomes of TAR with FET; it is unsurprising therefore that much research has been done to determine both the underlying cause thereof, and strategies to mitigate this risk. Mousavizadeh and colleagues produced a fascinating systematic review and meta-analysis investigating the relationship between the duration of hypothermic circulatory arrest (HCA) and the risk of developing complications including SCI and stroke. Their data seem to suggest HCA duration is a key factor in causing SCI and stroke following TAR with FET for ATAAD. However, other factors such as stent sizing and landing zone also contribute. Further prospective research into this relationship is recommended to fully elucidate what truly is to blame for these postoperative neurological complications.