Is a four-branched prosthesis advantageous over a straight prosthesis in Frozen elephant trunk surgery?

For years, the elephant trunk (ET) technique has been applied to extended aortic arch pathology facilitating staged downstream open- or endovascular completion. The recent use of a stentgraft as so-called frozen ET enables even single-stage repair, or its use as a scaffold in an acutely or chronically dissected aorta. Hybrid prosthesis have since been introduced, available as either a 4-branch graft or a straight graft for reimplantation of the arch vessels using the classic island technique. Both techniques are known to have technical advantages and disadvantages in specific surgical scenarios. In this paper we will discuss whether a 4-branch graft hybrid prosthesis is advantageous over a straight hybrid prosthesis. Our considerations in terms of mortality, cerebral embolic risk, myocardial ischemia time, cardiopulmonary bypass (CPB) time, hemostasis and exclusion of supra-aortic entries in the case of acute dissection will be shared. The 4-branch graft hybrid prosthesis conceptually facilitates reduced systemic-, cerebral-, and cardiac arrest time. Additionally, atherosclerotic ostial debris, intimal re-entries, and fragile aortic tissue in genetic disease can be excluded by using a branched graft instead of the island technique for reimplantation of the arch vessels. Despite many conceptual technical advantages of the 4-branch graft hybrid prosthesis, literature data do not show significantly better outcomes when compared to the straight graft, to support its routine use in all cases.