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Page 2 of 7 Di Marco et al. Vessel Plus 2020;4:32 I http://dx.doi.org/10.20517/2574-1209.2020.23

A B C

D E F

Figure 1. Frozen elephant trunk procedure with Thoraflex hybrid prosthesis in a case of acute type B aortic dissection. Pre-operative
computed tomography (CT)-angiogram shows the entry tear downstream of the left subclavian artery and the dissected descending
thoracic and thoracoabdominal aorta (A, B, C); two years-follow up CT-angiogram shows the complete peri-stent false lumen
thrombosis (D, E, F)

The FET procedure is indicated in chronic thoracic aorta dissection, acute and chronic Stanford type B
aortic dissection [Figure 1], when endovascular treatment is not feasible or contraindicated, and chronic
degenerative aneurysms of the thoracic aorta and distal arch. Another indication is acute Stanford type
A aortic dissection [Figure 2], especially when distal malperfusion occurs and when the intimal tear is
located in the distal aortic arch or in the proximal descending thoracic aorta. A recently published position
statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society
for Vascular Surgery defines specific classes of recommendations to the aforementioned indications: in
particular, class IIA is given to the cited cases of acute type A and type B aortic dissection and to aortic
disease involving distal thoracic and thoraco-abdominal aorta, that is likely to require, at a later stage,
either surgical or endovascular treatment. On the other hand, class IIB recommendation is given to type A
[6]
aortic dissection to prevent aneurysms development in the downstream aorta .
There are two available hybrid stent grafts for FET procedure in Europe with CE (Conformité Européenne)
mark approval: the E-Vita Open and E-Vita Open Plus (Jotec GmbH, Hechingen, Germany) and the
Thoraflex (Vascutek, Terumo, Inchinnan, Scotland, UK) [Figure 3]. These two grafts both are composed
of a proximal gel-coated woven polyester tubular graft and a distal self-expanding stent graft made of
polyester and nitinol ring stents. The two grafts differ from each other by the presence of three side
branches for the arch vessels in the Vascutek Thoraflex prosthesis; on the other hand, the E-Vita Open Plus
is a single tubular graft and the arch vessels are implanted on it with the “island” technique.

Our experience with FET procedure started in 2007 with a total of 318 procedures: 173 were carried out
using the E-Vita Open hybrid prosthesis and 145 using the Thoraflex. The indications for FET procedure
were chronic degenerative aortic aneurysms in 82 patients, acute type A aortic dissection in 44 patients,
residual dissection in operated acute type A aortic dissection in 119 patients, chronic type A aortic