Delayed impingement of a frozen elephant trunk into the native aortic wall after total arch replacement

Delayed impingement of a frozen elephant trunk into the native aortic wall after total arch replacement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Delayed impingement of a frozen elephant trunk into the native aortic wall after total arch replacement Jin Kato, Kenichi Hashizume, Hideyuki Shimizu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8335602/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract We report a rare case of severe distal aortic arch deformation with flexural deformity occurring in the long-term follow-up period after total aortic arch replacement with a frozen elephant trunk stent-graft (TAR-FET) (TAR-FET) for aortic dissection. The patient required re-arch replacement using FET and staged TEVAR, which completely restored the morphological deformity. Caution is warranted regarding aortic wall vulnerability and the spring-back force of FET, highlighting the importance of long-term follow-up. Aortic dissection Frozen Elephant Trunk Computed tomography Migration Figures Figure 1 Figure 2 Introduction Multiple large cohort and comparative studies have demonstrated a low incidence of late aortic events (re-expansion, reoperation, aneurysm formation, etc.).[ 1 – 3 ] Reported complications include distal bending, iatrogenic stenosis, and distal stent-induced new entry (dSINE). Additional distal interventions after FET occur in 11% of acute dissections and 28% of chronic aneurysms. Case Presentation The patient is a 60-year-old male. Five years prior, he underwent TAR + FET at another institution for acute Stanford Type A dissection. Immediately postoperatively, rupture at the central anastomosis site necessitated additional ascending aorta replacement and left subclavian artery bypass. The postoperative course was uneventful with no signs of organ ischemia, and he was managed as an outpatient. Follow-up CT revealed severe bending deformity (Fig. 1 -c, red arrowhead) in the aortic arch distal to the FET placement site, indicating progressive migration of the FET proximally (Fig. 1 -a, 1 -b, yellow arrowhead). A new small aneurysm (white arrow) was also noted at the anastomotic site. The patient reported no blood pressure differences between upper and lower limbs, nor any complaints of lower limb coldness, pain, or neurological symptoms. Given the new appearance of a central anastomotic pseudoaneurysm and the history of a central anastomotic rupture postoperatively, semi-urgent surgical intervention was planned. Furthermore, progressive proximal migration of the FET contributed to the arch deformity. Given the potential risk of future flow impairment, additional intervention was deemed necessary.. Considering the risk of future blood flow impairment, a policy of additional intervention was decided. The surgical approach selected was ascending replacement (Lupiae 26 mm), a new FET (Frozenix 25/150 mm), and Bentall procedure (Inspiris Resilia 25 mm + Gelweave Valsalva 28 mm) (Fig. 2 -a). On postoperative day 1, a significant upper-lower limb blood pressure difference (> 40 mmHg, ABI 0.62). CT imaging revealed the distal end of the FET detached from the descending aorta, with the existing entry point of the Stanford type aortic dissection visible at its lower margin. This was considered the cause of the blood flow impairment, leading to an emergency additional TEVAR (peripheral: C-TAG 26 − 1 mm, central: C-TAG 28–150 mm). Postoperative CT confirmed resolution of the pseudoaneurysm and elimination of aortic arch kinking (Fig. 2 -b, 2 -c). The upper-lower limb blood pressure difference resolved, with ABI improving to 0.80. No postoperative neurological deficits or circulatory compromise were observed. The patient progressed favorably and was discharged without complications on postoperative day 15. Discussion This case describes a 60-year-old male who underwent total aortic arch replacement with a frozen elephant trunk (FET) graft for acute Stanford type A aortic dissection. Distal complications including proximal graft migration and severe flexion deformity of the distal aortic arch developed in the long term. These long-term complications following FET (graft migration, bending, dSINE, pseudoaneurysm, hemodynamic compromise) represent clinically significant events. Multiple evidence sources support the necessity of regular imaging follow-up, even in asymptomatic cases.[ 1 – 5 ] Inappropriate landing zones for FET grafts increase the risk of proximal migration, aortic arch deformation, new entry points (dSINE/pSINE), and blood flow compromise. The 2024 EACTS/STS guidelines emphasize the importance of establishing an adequate sealing zone and implementing individualized monitoring programs. They recommend increasing the frequency of imaging follow-up, particularly in dissection cases and endovascular treatment cases, due to the elevated risk of long-term aortic events.[ 1 – 3 ] Regarding imaging follow-up, guidelines from The Society of Thoracic Surgeons and The American College of Cardiology recommend periodic imaging surveillance via CTA or MRI after FET. Specifically, imaging evaluation is recommended at 1 month, 3 months, 6 months, 12 months postoperatively, and annually thereafter. Lifelong monitoring is required even in stable cases. Even in asymptomatic patients, complications such as graft migration, kinking, dissection enlargement, or pseudoaneurysm formation can occur in the long term, highlighting the high utility of imaging follow-up.[ 1 – 2 ][ 4 ][ 6 – 10 ] The long-term reintervention rate after FET is reported to be approximately 10–20%, with most reinterventions being TEVAR or additional surgical procedures. Early detection and intervention have also been shown to contribute to improved prognosis, highlighting the importance of early detection of complications through imaging follow-up.[ 3 – 5 ][ 8 – 12 ] However, data regarding the optimal frequency and method of imaging follow-up, as well as long-term prognosis, remain limited. Accumulating further long-term data and optimizing imaging surveillance protocols are identified as future challenges. Conclusion Long-term imaging follow-up is necessary after performing FET for Stanford Type A acute aortic dissection. Declarations Ethical approval was waived for this single case report. Written informed consent for publication of this case and accompanying images was obtained from the patient. Conflict of interest: none declared. Author Contribution Conceptualization: Dr KatoData curation: Dr. KatoWriting – original draft: Dr. KatoWriting – review & editing: Dr. HashizumeSupervision: Dr. Hashizume, Dr. Shimizu Funding ／ COI ／ Author Contributions （ CRediT ） This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflict of interest: none declared. Conceptualization: Dr Kato Data curation: Dr. Kato Writing – original draft: Dr. Kato Writing – review & editing: Dr. Hashizume Supervision: Dr. Hashizume, Dr. Shimizu References Czerny M, Grabenwöger M, Berger T, et al. EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg. 2024;65(2):ezad426. 10.1093/ejcts/ezad426 . Carrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet. 2023;401(10378):773–88. 10.1016/S0140-6736(22)01970-5 . Doonan RJ, Senanayake E, Claridge M, et al. Distal repair after total aortic arch replacement with frozen elephant trunk in patients with chronic multilevel thoracic aortic disease. Eur J Vasc Endovasc Surg. 2024;68(1):73–81. 10.1016/j.ejvs.2024.02.032 . Borghese O, Sajiram S, Lee M, et al. Frozen elephant trunk procedure for acute type A aortic dissection: analysis of distal aortic remodeling according to the SVS/STS reporting standard. Ann Vasc Surg. 2024;108:346–54. 10.1016/j.avsg.2024.06.009 . Di Bartolomeo R, Pantaleo A, Berretta P, et al. Frozen elephant trunk surgery in acute aortic dissection. J Thorac Cardiovasc Surg. 2015;149(2 Suppl):S105–9. 10.1016/j.jtcvs.2014.07.098 . Heuts S, Schalla S, Ramaekers MJFG, et al. Imaging surveillance for complications after primary surgery for type A aortic dissection. Heart. 2022;109(2):96–101. 10.1136/heartjnl-2022-320881 . Malaisrie SC, Szeto WY, Halas M, et al. 2021 The American Association for Thoracic Surgery expert consensus document: surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg. 2021;162(3):735–e7582. 10.1016/j.jtcvs.2021.04.053 . Zhang K, Qiu J, Wu J, et al. Long-term outcomes in total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2024;S0022–5223(24):01106–1. 10.1016/j.jtcvs.2024.11.025 . Leone A, Beckmann E, Martens A, et al. Total aortic arch replacement with frozen elephant trunk technique: results from two European institutes. J Thorac Cardiovasc Surg. 2020;159(4):1201–11. 10.1016/j.jtcvs.2019.03.121 . Yamamoto H, Kadohama T, Yamaura G, et al. Total arch repair with frozen elephant trunk using the zone 0 arch repair strategy for type A acute aortic dissection. J Thorac Cardiovasc Surg. 2020;159(1):36–45. 10.1016/j.jtcvs.2019.01.125 . Iino K, Takago S, Saito N, et al. Total arch replacement and frozen elephant trunk for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2022;164(5):1400–e14093. 10.1016/j.jtcvs.2020.10.135 . Iida Y, Fujii S, Shimizu H, Sawa S. Patterns of aortic remodelling after total arch replacement with frozen elephant trunk for acute aortic dissection. Interact Cardiovasc Thorac Surg. 2019;29(6):923–9. 10.1093/icvts/ivz185 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 24 Mar, 2026 Reviews received at journal 15 Feb, 2026 Reviews received at journal 15 Feb, 2026 Reviews received at journal 15 Feb, 2026 Reviewers agreed at journal 05 Feb, 2026 Reviewers agreed at journal 04 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers invited by journal 02 Feb, 2026 Editor assigned by journal 13 Dec, 2025 Submission checks completed at journal 13 Dec, 2025 First submitted to journal 11 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8335602","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":584604392,"identity":"4dc8cb50-0234-498a-a850-c087ec1d8be9","order_by":0,"name":"Jin Kato","email":"","orcid":"","institution":"Keio University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jin","middleName":"","lastName":"Kato","suffix":""},{"id":584604394,"identity":"a7c19a81-ba04-4a80-abff-698c5ee80b5d","order_by":1,"name":"Kenichi Hashizume","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYBACAwYGNoYEEIuH+TCYy9hAvBa2ZBK0gAEPjzFxDjNnP/7swYM/h6P5ec58NvhQYMPAPJuANZY9OeYGCTyHc2f29m5OnGGQxsA45wABhx3IYZNIkDicu+E87+bDPAaHGRhnJBDQcv75M4kEg8O5+8/zPD78hygtNxLMJBISgLbw9jAnMxCn5Q1Qy4H03Blnjhkb9hik8RD2y/n0Z5I//ljn9vckP5b48cdGzpBQiGEAHsMZJOpgYJCXIFnLKBgFo2AUDHMAAJTsRv7c6bGLAAAAAElFTkSuQmCC","orcid":"","institution":"Keio University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Kenichi","middleName":"","lastName":"Hashizume","suffix":""},{"id":584604395,"identity":"d374b14d-4f32-41af-b8ac-75ab753b2bf8","order_by":2,"name":"Hideyuki Shimizu","email":"","orcid":"","institution":"Keio University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hideyuki","middleName":"","lastName":"Shimizu","suffix":""}],"badges":[],"createdAt":"2025-12-11 10:38:32","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8335602/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8335602/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101874939,"identity":"8bd6bc63-10f0-43fc-8cc8-e2e19bcef9d8","added_by":"auto","created_at":"2026-02-04 14:05:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":898833,"visible":true,"origin":"","legend":"\u003cp\u003e(a, b) Postoperative follow-up CT after TAR + FET. The distal end of the FET has migrated toward the proximal aorta (yellow arrowheads).\u003c/p\u003e\n\u003cp\u003e(c) Curvature deformity is observed in the aortic arch distal to the FET anastomosis (red arrowhead).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8335602/v1/a445ffe86a9e71f32ab500fa.png"},{"id":101874940,"identity":"8d894a2c-a129-4e2f-aeab-8c50044e9c39","added_by":"auto","created_at":"2026-02-04 14:05:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":746756,"visible":true,"origin":"","legend":"\u003cp\u003e(a) CT scan obtained on the day after re-arch replacement and Bentall procedure. A new FET graft was implanted in the deformed aortic arch segment, while residual dissection with a patent false lumen remained in the descending aorta.\u003c/p\u003e\n\u003cp\u003e(b, c) Emergency TEVAR was subsequently performed, resulting in closure of the entry site and restoration of aortic configuration.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8335602/v1/2f4874a98333eac15beaf20e.png"},{"id":101874944,"identity":"64eecd70-aa1a-4eb1-99ed-97ca2104f99c","added_by":"auto","created_at":"2026-02-04 14:05:38","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2298002,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8335602/v1/8f25cbc4-5ea9-4b7b-a1e7-761a0e5b6b61.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Delayed impingement of a frozen elephant trunk into the native aortic wall after total arch replacement","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMultiple large cohort and comparative studies have demonstrated a low incidence of late aortic events (re-expansion, reoperation, aneurysm formation, etc.).[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eReported complications include distal bending, iatrogenic stenosis, and distal stent-induced new entry (dSINE). Additional distal interventions after FET occur in 11% of acute dissections and 28% of chronic aneurysms.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eThe patient is a 60-year-old male.\u003c/p\u003e \u003cp\u003eFive years prior, he underwent TAR\u0026thinsp;+\u0026thinsp;FET at another institution for acute Stanford Type A dissection. Immediately postoperatively, rupture at the central anastomosis site necessitated additional ascending aorta replacement and left subclavian artery bypass. The postoperative course was uneventful with no signs of organ ischemia, and he was managed as an outpatient.\u003c/p\u003e \u003cp\u003eFollow-up CT revealed severe bending deformity (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-c, red arrowhead) in the aortic arch distal to the FET placement site, indicating progressive migration of the FET proximally (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-a, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-b, yellow arrowhead). A new small aneurysm (white arrow) was also noted at the anastomotic site. The patient reported no blood pressure differences between upper and lower limbs, nor any complaints of lower limb coldness, pain, or neurological symptoms.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGiven the new appearance of a central anastomotic pseudoaneurysm and the history of a central anastomotic rupture postoperatively, semi-urgent surgical intervention was planned. Furthermore, progressive proximal migration of the FET contributed to the arch deformity. Given the potential risk of future flow impairment, additional intervention was deemed necessary.. Considering the risk of future blood flow impairment, a policy of additional intervention was decided. The surgical approach selected was ascending replacement (Lupiae 26 mm), a new FET (Frozenix 25/150 mm), and Bentall procedure (Inspiris Resilia 25 mm\u0026thinsp;+\u0026thinsp;Gelweave Valsalva 28 mm) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e-a). On postoperative day 1, a significant upper-lower limb blood pressure difference (\u0026gt;\u0026thinsp;40 mmHg,\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eABI 0.62). CT imaging revealed the distal end of the FET detached from the descending aorta, with the existing entry point of the Stanford type aortic dissection visible at its lower margin. This was considered the cause of the blood flow impairment, leading to an emergency additional TEVAR (peripheral: C-TAG 26\u0026thinsp;\u0026minus;\u0026thinsp;1 mm, central: C-TAG 28\u0026ndash;150 mm). Postoperative CT confirmed resolution of the pseudoaneurysm and elimination of aortic arch kinking (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e-b, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e-c). The upper-lower limb blood pressure difference resolved, with ABI improving to 0.80. No postoperative neurological deficits or circulatory compromise were observed. The patient progressed favorably and was discharged without complications on postoperative day 15.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case describes a 60-year-old male who underwent total aortic arch replacement with a frozen elephant trunk (FET) graft for acute Stanford type A aortic dissection. Distal complications including proximal graft migration and severe flexion deformity of the distal aortic arch developed in the long term. These long-term complications following FET (graft migration, bending, dSINE, pseudoaneurysm, hemodynamic compromise) represent clinically significant events. Multiple evidence sources support the necessity of regular imaging follow-up, even in asymptomatic cases.[\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eInappropriate landing zones for FET grafts increase the risk of proximal migration, aortic arch deformation, new entry points (dSINE/pSINE), and blood flow compromise. The 2024 EACTS/STS guidelines emphasize the importance of establishing an adequate sealing zone and implementing individualized monitoring programs. They recommend increasing the frequency of imaging follow-up, particularly in dissection cases and endovascular treatment cases, due to the elevated risk of long-term aortic events.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eRegarding imaging follow-up, guidelines from The Society of Thoracic Surgeons and The American College of Cardiology recommend periodic imaging surveillance via CTA or MRI after FET. Specifically, imaging evaluation is recommended at 1 month, 3 months, 6 months, 12 months postoperatively, and annually thereafter. Lifelong monitoring is required even in stable cases. Even in asymptomatic patients, complications such as graft migration, kinking, dissection enlargement, or pseudoaneurysm formation can occur in the long term, highlighting the high utility of imaging follow-up.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e][\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eThe long-term reintervention rate after FET is reported to be approximately 10\u0026ndash;20%, with most reinterventions being TEVAR or additional surgical procedures. Early detection and intervention have also been shown to contribute to improved prognosis, highlighting the importance of early detection of complications through imaging follow-up.[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e][\u003cspan additionalcitationids=\"CR9 CR10 CR11\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHowever, data regarding the optimal frequency and method of imaging follow-up, as well as long-term prognosis, remain limited. Accumulating further long-term data and optimizing imaging surveillance protocols are identified as future challenges.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLong-term imaging follow-up is necessary after performing FET for Stanford Type A acute aortic dissection.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval was waived for this single case report. Written informed consent for publication of this case and accompanying images was obtained from the patient.\u003c/p\u003e\u003ch2\u003eConflict of interest:\u003c/h2\u003e \u003cp\u003enone declared.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: Dr KatoData curation: Dr. KatoWriting \u0026ndash; original draft: Dr. KatoWriting \u0026ndash; review \u0026amp; editing: Dr. HashizumeSupervision: Dr. Hashizume, Dr. Shimizu\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cstrong\u003e／\u003c/strong\u003e\u003cstrong\u003eCOI\u003c/strong\u003e\u003cstrong\u003e／\u003c/strong\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003cstrong\u003e（\u003c/strong\u003e\u003cstrong\u003eCRediT\u003c/strong\u003e\u003cstrong\u003e）\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003eConflict of interest: none declared.\u003c/p\u003e\n\u003cp\u003eConceptualization: Dr Kato\u003c/p\u003e\n\u003cp\u003eData curation: Dr. Kato\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; original draft: Dr. Kato\u003c/p\u003e\n\u003cp\u003eWriting \u0026ndash; review \u0026amp; editing: Dr. Hashizume\u003c/p\u003e\n\u003cp\u003eSupervision: Dr. Hashizume, Dr. Shimizu\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCzerny M, Grabenw\u0026ouml;ger M, Berger T, et al. EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg. 2024;65(2):ezad426. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ejcts/ezad426\u003c/span\u003e\u003cspan address=\"10.1093/ejcts/ezad426\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet. 2023;401(10378):773\u0026ndash;88. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(22)01970-5\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(22)01970-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoonan RJ, Senanayake E, Claridge M, et al. Distal repair after total aortic arch replacement with frozen elephant trunk in patients with chronic multilevel thoracic aortic disease. Eur J Vasc Endovasc Surg. 2024;68(1):73\u0026ndash;81. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ejvs.2024.02.032\u003c/span\u003e\u003cspan address=\"10.1016/j.ejvs.2024.02.032\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorghese O, Sajiram S, Lee M, et al. Frozen elephant trunk procedure for acute type A aortic dissection: analysis of distal aortic remodeling according to the SVS/STS reporting standard. 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Interact Cardiovasc Thorac Surg. 2019;29(6):923\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/icvts/ivz185\u003c/span\u003e\u003cspan address=\"10.1093/icvts/ivz185\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Aortic dissection, Frozen Elephant Trunk, Computed tomography, Migration","lastPublishedDoi":"10.21203/rs.3.rs-8335602/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8335602/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report a rare case of severe distal aortic arch deformation with flexural deformity occurring in the long-term follow-up period after total aortic arch replacement with a frozen elephant trunk stent-graft (TAR-FET) (TAR-FET) for aortic dissection. The patient required re-arch replacement using FET and staged TEVAR, which completely restored the morphological deformity. Caution is warranted regarding aortic wall vulnerability and the spring-back force of FET, highlighting the importance of long-term follow-up.\u003c/p\u003e","manuscriptTitle":"Delayed impingement of a frozen elephant trunk into the native aortic wall after total arch replacement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-04 14:05:28","doi":"10.21203/rs.3.rs-8335602/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-24T15:33:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-15T22:19:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-15T17:11:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-15T13:43:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69616629493493652247346035365480173771","date":"2026-02-05T10:11:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53609684951079025966025411879987034497","date":"2026-02-04T15:37:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"172175807470300424569071320458944174323","date":"2026-02-02T16:00:37+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14818333121557176153366609514515431894","date":"2026-02-02T15:50:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-02T15:21:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-13T06:13:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-13T06:13:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-12-11T10:10:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b26b3195-c814-422e-9374-8f05ed3ffc67","owner":[],"postedDate":"February 4th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-25T20:53:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-04 14:05:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8335602","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8335602","identity":"rs-8335602","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}