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Geragotellis et al. Vessel Plus 2023;7:6 Vessel Plus
DOI: 10.20517/2574-1209.2022.41

Review Open Access

Head-to-head: Zone 2 vs. Zone 3 frozen elephant

trunk

4
1,#
5
3
2,#
Alexander Geragotellis , Matti Jubouri , Kamran Hussain , Waseem Alzaanin , Sven ZCP Tan , Ravi
2
6
Patel , Idhrees Mohammed , Mohamad Bashir 6,7
1
Faculty of Health Sciences, University of Cape Town, Cape Town 7935, South Africa.
2
Hull York Medical School, University of York, York YO10 5DD, UK.
3
East Lancashire Teaching Hospitals NHS Trust, Blackburn BB2 3HH, UK.
4
Faculty of Medicine, Al-Quds University, Jerusalem, Palestine.
5
Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London E1 2AD, UK.
6
Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science, Chennai, Tamil Nadu 600083, India.
7
Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff
CF15 7QZ, UK.
#
Authors contributed equally and considered joint first authors.
Correspondence to: Prof. Mohamad Bashir, Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education
& Improvement Wales, Cardiff CF15 7QZ, UK. E-mail: drmobashir@outlook.com
How to cite this article: Geragotellis A, Jubouri M, Hussain K, Alzaanin W, Tan SZ, Patel R, Mohammed I, Bashir M. Head-to-
head: Zone 2 vs. Zone 3 frozen elephant trunk. Vessel Plus 2023;7:6. https://dx.doi.org/10.20517/2574-1209.2022.41
Received: 29 Jun 2022 First Decision: 11 Aug 2022 Revised: 28 Sep 2022 Accepted: 7 Mar 2023 Published: 13 Mar 2023
Academic Editor: Frank W. Sellke Copy Editor: Ying Han Production Editor: Ying Han
Abstract
Total arch replacement via frozen elephant trunk (FET) is a strategy for managing complex thoracic aortic
pathologies involving the arch and descending thoracic aorta (DTA). The FET procedure involves the distal
anastomosis of the FET hybrid prosthesis at a chosen aortic arch zone. Though distal anastomosis has been
traditionally performed at Zone 3 (Z-3-FET) of the aortic arch, recent practice has seen a significant increase in
Zone 2 FET (Z-2-FET). The literature concerning independent Zone 2 and 3 studies and head-to-head comparative
studies suggest that Z-2-FET is the superior approach, yielding more favourable results overall, except for aortic
remodelling. The improved clinical outcomes achieved with Z-2-FET can be attributed to the shorter operative
times, including cardiopulmonary bypass duration, due to the ease and increased surgical site exposure at the
aortic arch using this technique. The slightly inferior aortic remodelling observed in Z-2-FET can be explained by
the decreased coverage of the DTA distally by the FET stent graft. However, this difference in results can also be
attributed to the complexity and severity of the underlying pathology and the surgical approach adopted. The
prospect of utilising Zone 0 FET (Z-0-FET) is highly promising, with some studies hinting at its superiority over Z-
2-FET. Nevertheless, studies are needed to determine the efficacy of Z-0-FET and directly compare it to Z-2-FET to

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