Florida Elephant Trunk Hybrid Aortic Repair (FETHAR): a novel frozen elephant trunk technique with complete debranching sparing endograft modification

Florida Elephant Trunk Hybrid Aortic Repair (FETHAR): a novel frozen elephant trunk technique with complete debranching sparing endograft modification | 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 Florida Elephant Trunk Hybrid Aortic Repair (FETHAR): a novel frozen elephant trunk technique with complete debranching sparing endograft modification Christopher Bobba, Omar Sharaf, Fabian Jimenez Contreras, Thomas Beaver, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8264340/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Hybrid aortic repair entails a combination of open surgical and endovascular techniques. Existing techniques require modification of endografts to allow for complete arch debranching using a combination of open and endovascular techniques which may predispose the graft to failure or endoleak. We report on a novel method for hybrid aortic repair using a trifurcated graft, a collared Siena graft utilized in reversed fashion, a TEVAR stent graft, and a covered vascular graft. We demonstrate excellent seal without endoleak on the post-operative CT scan. Ultimately, this repair allows for complete arch debranching, an anastomosis in zone 2 of the aortic arch, and no endograft modification. Figures Figure 1 Figure 2 Introduction Hybrid aortic repair entails a combination of open surgical and endovascular techniques. Existing techniques in the aortic arch require modification of an endovascular graft to achieve this goal. We report on a novel method for hybrid aortic repair using a trifurcated graft, a collared Siena graft utilized in reversed fashion, a TEVAR stent graft, and a covered vascular graft (Fig. 1 ). Case Report and Technique A 64 year-old male presented with hyperacute aortic dissection with a contained rupture into the left pleural space. Imaging indicated a type I dissection with tear in zone 4 and significant ascending and arch involvement along with large left hemothorax (Fig. 2 A). The patient elected to proceed with emergent repair. We planned to repair his dissection initially without draining the hemothorax until we could assure complete coverage of his rupture. Upon sternotomy and aortic inspection there was clear hematoma and dissection consistent with the imaging. Wire access was obtained in the true lumen of the femoral artery, confirmed on transesophageal echocardiography, and left in the descending thoracic aorta (Fig. 1 A). Epiaortic ultrasound identified an appropriate site for cannulation in the true lumen of the ascending aorta. Transesophageal echocardiogram did not identify aortic valve or root pathology. The patient was placed on cardiopulmonary bypass with central aortic and dual stage venous cannulation with retrograde cardioplegia and a left ventricular vent. The patient was cooled to 18C with electrocerebral silence, placed in Trendelenburg position, and we initiated deep hypothermic circulatory arrest. A trifurcated Gelweave graft was brought to the field and anastomosis to the innominate artery was completed. Unilateral antegrade cerebral perfusion was initiated after 19 minutes.. Anastomosis to the left common carotid artery was then completed, and bilateral antegrade cerebral perfusion via innominate and left common carotid arteries was initiated. Visual inspection of the distal arch and proximal descending thoracic aorta revealed a large tear in zone 4. A collared Siena graft with single side arm was trimmed, reversed, and floated antegrade into zone 3. The sidearm of the reversed collared graft was then positioned into the orifice of the left subclavian artery. The distal aortic anastomosis was then completed in zone 2 using a horizontal mattress felt sandwich technique around the diseased aorta, which was then anastomosed to the graft collar (Fig. 1 B). The previously placed Amplatz femoral wire was then advanced retrograde through our distal anastomosis, such that through-and-through wire access was obtained. A TEVAR endograft was then deployed in antegrade fashion over that wire (Fig. 1 C). A Viabahn stent was then deployed in antegrade fashion through the collared Siena graft and into the sidearm previously floated within the left subclavian artery. Excellent retrograde flow was observed through the left subclavian artery stent once deployed without any apparent endoleak around the stent or from the left subclavian orifice. A straight Gelweave graft with sidearm was then anastomosed to the distal aortic anastomosis and flow was restored to the body (56 minutes of antegrade cerebral perfusion, and 75 minutes total body ischemic time). Next we performed our proximal aortic anastomosis, then anastomosed the trifurcated graft to the straight graft and the operation was completed (Fig. 1 D). Deep hypothermic circulatory arrest time was 19 minutes. Body circulatory arrest with antegrade cerebral perfusion time was 56 minutes. Cross-clamp time was 114 minutes and total time on cardiopulmonary bypass was 196 minutes. The patient tolerated the procedure well and was transported to the ICU. The following day he underwent a CT scan to ensure complete coverage of his rupture within the descending thoracic aorta, and we elected to extend his TEVAR on POD2 using the Knickerbocker technique to ensure complete coverage of his tear. This scan also indicated patent flow within the LSCA and no evidence of endoleak or pseudoaneurysm from the Siena graft, LSCA stent, or TEVAR stent (Fig. 2 B). On POD 4, we performed left VATS for washout of his hemothorax. Thereafter he recovered well and was extubated on POD 6. Comment Hybrid aortic arch repair has emerged as a viable treatment strategy for complex aortic pathology involving the aortic arch and proximal descending thoracic aorta [ 1 , 2 ]. Initially this repair entailed antegrade deployment of a thoracic endovascular aortic repair (TEVAR) graft in conjunction with individual debranching of the head vessels via standard open surgical anastomosis. More recently the B-SAFER has demonstrated successful modification of TEVAR endografts to allow for endovascular revascularization of the left subclavian artery with or without the left common carotid artery, and standard anastomosis to the innominate artery [ 3 , 4 , 5 ]. The advantages of this technique are to move the distal anastomosis “forward” (i.e. away from zone 3 to zone 2 or 1), reduce the number of surgical anastomoses, and avoid surgical dissection injury to the recurrent laryngeal nerve. These serve to reduce bleeding complications, circulatory arrest time, total operative time, and post-operative morbidity. One disadvantage, however, is that all variants of this technique require endograft modification (with electrocautery or mechanical cutting). We conjecture that this could weaken the graft and predispose it to failure or endoleak. Various commercial devices have been developed to better facilitate hybrid repairs but all require standard surgical anastomosis to the head vessels. We developed this technique to capitalize on the advantages of B-SAFER (i.e. allow for endovascular revascularization of the left subclavian artery) while avoiding modification of commercially available endografts. In this patient we were able to visualize the orifice of the left subclavian artery to float a short segment of a sidearm graft and then deploy a covered stent into the left subclavian artery in antegrade fashion. Post-operative imaging indicated good seal without endoleak. This approach combines the advantages of hybrid aortic repair while minimizing any necessary endograft modification, and is a viable option for hybrid aortic repair. Abbreviations TEVAR thoracic endovascular aortic repair POD post-operative day LSCA left subclavian artery VATS video assisted thoracoscopic surgery B-SAFER branched stented anastomosis frozen elephant trunk repair Declarations Disclosure statement: The authors have no disclosures relevant to the publication of this work. Funding statement: The authors have no funding relevant to the publication of this work. IRB: The University does not require IRB approval for publication of case reports involving one patient, however, the patient did provide written informed consent for the publication of this case report. Informed Consent Statement: The patient provided written informed consent for the publication of this case report. Author Contribution CB and EJ wrote the main manuscript text. CB, OS, and FJ prepared the figures. TB, TM, and EJ provided insight into the details of writing the technique. All authors provided editorial work and reviewed the final manuscript. References Sharaf OM, Kohtz PD, Arnaoutakis GJ. Aortic Arch Repair Using Open and Hybrid Techniques: A Systematic Review. Innovations (Phila). 2022 Jul-Aug;17(4):273–282. 10.1177/15569845221115355 . Epub 2022 Aug 8. PMID: 35934948. Milewski RK, Szeto WY, Pochettino A, Moser GW, Moeller P, Bavaria JE. Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J Thorac Cardiovasc Surg. 2010;140(3):590-7. 10.1016/j.jtcvs.2010.02.055 . PMID: 20723729. Roselli EE, Rafael A, Soltesz EG, Canale L, Lytle BW. Simplified frozen elephant trunk repair for acute DeBakey type I dissection. J Thorac Cardiovasc Surg. 2013;145(3 Suppl):S197-201. 10.1016/j.jtcvs.2012.11.068 . Epub 2012 Dec 20. PMID: 23260435. Roselli EE, Idrees JJ, Bakaeen FG, Tong MZ, Soltesz EG, Mick S, Johnston DR, Eagleton MJ, Menon V, Svensson LG. Evolution of Simplified Frozen Elephant Trunk Repair for Acute DeBakey Type I Dissection: Midterm Outcomes. Ann Thorac Surg. 2018;105(3):749–55. Epub 2017 Dec 6. PMID: 29217087. Roselli EE, Vargo PR, Bakaeen F, Koprivanac M, Burns D, Kuramochi Y, Gillinov M, B-SAFER, Investigators. Branched stented anastomosis frozen elephant trunk repair: Early results from a physician-sponsored investigational device exemption study. J Thorac Cardiovasc Surg. 2023 Oct 5:S0022-5223(23)00895-4. doi: 10.1016/j.jtcvs.2023.09.069. Epub ahead of print. PMID: 37802330. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers invited by journal 29 Jan, 2026 Editor assigned by journal 09 Dec, 2025 Submission checks completed at journal 09 Dec, 2025 First submitted to journal 02 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. 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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-8264340","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":583513933,"identity":"20d9fc31-a278-4bf2-b517-1b2099171cbc","order_by":0,"name":"Christopher Bobba","email":"data:image/png;base64,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","orcid":"","institution":"University of Florida","correspondingAuthor":true,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Bobba","suffix":""},{"id":583513934,"identity":"295216c0-a5b9-46e9-bab4-a54fdd507c85","order_by":1,"name":"Omar Sharaf","email":"","orcid":"","institution":"University of Florida","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Sharaf","suffix":""},{"id":583513935,"identity":"fe1f31b8-838b-4ac7-aef7-ac776983180b","order_by":2,"name":"Fabian Jimenez Contreras","email":"","orcid":"","institution":"University of Florida","correspondingAuthor":false,"prefix":"","firstName":"Fabian","middleName":"Jimenez","lastName":"Contreras","suffix":""},{"id":583513936,"identity":"c8cb9eb5-9dbc-4a63-ae85-6ceec749e63b","order_by":3,"name":"Thomas Beaver","email":"","orcid":"","institution":"University of Florida","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"","lastName":"Beaver","suffix":""},{"id":583513937,"identity":"e883b938-633c-498b-b045-783398cd44fb","order_by":4,"name":"Tomas Martin","email":"","orcid":"","institution":"University of Florida","correspondingAuthor":false,"prefix":"","firstName":"Tomas","middleName":"","lastName":"Martin","suffix":""},{"id":583513938,"identity":"cdff12b8-b657-4cf3-a10b-69d3f41bc958","order_by":5,"name":"Eric Jeng","email":"","orcid":"","institution":"University of Florida","correspondingAuthor":false,"prefix":"","firstName":"Eric","middleName":"","lastName":"Jeng","suffix":""}],"badges":[],"createdAt":"2025-12-02 22:23:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8264340/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8264340/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101786847,"identity":"9445f181-8487-446f-9e60-cd6eb452e8fa","added_by":"auto","created_at":"2026-02-03 15:43:51","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":741877,"visible":true,"origin":"","legend":"\u003cp\u003eA) Wire access obtained in the true lumen from femoral artery. B) After zone 2 debranching a Siena graft is reversed and passed into the descending aorta, the 8mm sidearm is advanced into the left subclavian artery and the wire is advanced into the field. C) Antegrade TEVAR is deployed and the wire is advanced antegrade into the left subclavian artery. D) A covered stent is deployed antegrade into the left subclavian artery and the graft-to-graft anastomoses are completed. ACP; antegrade cerebral perfusion\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8264340/v1/997bc541110b4dd0c758c6fc.jpeg"},{"id":101786848,"identity":"a059bc26-3c2c-4f72-a5e6-a69376922ce3","added_by":"auto","created_at":"2026-02-03 15:43:51","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":720682,"visible":true,"origin":"","legend":"\u003cp\u003eA) Pre-operative CT scan showing acute type A dissection involving ascending and arch aorta with likely distal arch tear (green arrow) and left hemothorax (blue arrow). B) Post-operative surveillance CT scan demonstrating complete arch repair and effective left subclavian stent seal without endoleak (red arrow).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-8264340/v1/02e1806b4e80b3bf0d64e4dd.jpeg"},{"id":101942802,"identity":"5aeb5a86-7653-4851-8fd8-55a5bfc9e46e","added_by":"auto","created_at":"2026-02-05 09:38:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1753104,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8264340/v1/3b3e6241-04fd-4b20-841d-97928a9f9102.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Florida Elephant Trunk Hybrid Aortic Repair (FETHAR): a novel frozen elephant trunk technique with complete debranching sparing endograft modification","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHybrid aortic repair entails a combination of open surgical and endovascular techniques. Existing techniques in the aortic arch require modification of an endovascular graft to achieve this goal. We report on a novel method for hybrid aortic repair using a trifurcated graft, a collared Siena graft utilized in reversed fashion, a TEVAR stent graft, and a covered vascular graft (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e"},{"header":"Case Report and Technique","content":"\u003cp\u003eA 64 year-old male presented with hyperacute aortic dissection with a contained rupture into the left pleural space. Imaging indicated a type I dissection with tear in zone 4 and significant ascending and arch involvement along with large left hemothorax (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). The patient elected to proceed with emergent repair. We planned to repair his dissection initially without draining the hemothorax until we could assure complete coverage of his rupture. Upon sternotomy and aortic inspection there was clear hematoma and dissection consistent with the imaging. Wire access was obtained in the true lumen of the femoral artery, confirmed on transesophageal echocardiography, and left in the descending thoracic aorta (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). Epiaortic ultrasound identified an appropriate site for cannulation in the true lumen of the ascending aorta. Transesophageal echocardiogram did not identify aortic valve or root pathology. The patient was placed on cardiopulmonary bypass with central aortic and dual stage venous cannulation with retrograde cardioplegia and a left ventricular vent. The patient was cooled to 18C with electrocerebral silence, placed in Trendelenburg position, and we initiated deep hypothermic circulatory arrest. A trifurcated Gelweave graft was brought to the field and anastomosis to the innominate artery was completed. Unilateral antegrade cerebral perfusion was initiated after 19 minutes.. Anastomosis to the left common carotid artery was then completed, and bilateral antegrade cerebral perfusion via innominate and left common carotid arteries was initiated. Visual inspection of the distal arch and proximal descending thoracic aorta revealed a large tear in zone 4. A collared Siena graft with single side arm was trimmed, reversed, and floated antegrade into zone 3. The sidearm of the reversed collared graft was then positioned into the orifice of the left subclavian artery. The distal aortic anastomosis was then completed in zone 2 using a horizontal mattress felt sandwich technique around the diseased aorta, which was then anastomosed to the graft collar (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). The previously placed Amplatz femoral wire was then advanced retrograde through our distal anastomosis, such that through-and-through wire access was obtained. A TEVAR endograft was then deployed in antegrade fashion over that wire (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). A Viabahn stent was then deployed in antegrade fashion through the collared Siena graft and into the sidearm previously floated within the left subclavian artery. Excellent retrograde flow was observed through the left subclavian artery stent once deployed without any apparent endoleak around the stent or from the left subclavian orifice. A straight Gelweave graft with sidearm was then anastomosed to the distal aortic anastomosis and flow was restored to the body (56 minutes of antegrade cerebral perfusion, and 75 minutes total body ischemic time). Next we performed our proximal aortic anastomosis, then anastomosed the trifurcated graft to the straight graft and the operation was completed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). Deep hypothermic circulatory arrest time was 19 minutes. Body circulatory arrest with antegrade cerebral perfusion time was 56 minutes. Cross-clamp time was 114 minutes and total time on cardiopulmonary bypass was 196 minutes. The patient tolerated the procedure well and was transported to the ICU. The following day he underwent a CT scan to ensure complete coverage of his rupture within the descending thoracic aorta, and we elected to extend his TEVAR on POD2 using the Knickerbocker technique to ensure complete coverage of his tear. This scan also indicated patent flow within the LSCA and no evidence of endoleak or pseudoaneurysm from the Siena graft, LSCA stent, or TEVAR stent (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB). On POD 4, we performed left VATS for washout of his hemothorax. Thereafter he recovered well and was extubated on POD 6.\u003c/p\u003e"},{"header":"Comment","content":"\u003cp\u003eHybrid aortic arch repair has emerged as a viable treatment strategy for complex aortic pathology involving the aortic arch and proximal descending thoracic aorta [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Initially this repair entailed antegrade deployment of a thoracic endovascular aortic repair (TEVAR) graft in conjunction with individual debranching of the head vessels via standard open surgical anastomosis. More recently the B-SAFER has demonstrated successful modification of TEVAR endografts to allow for endovascular revascularization of the left subclavian artery with or without the left common carotid artery, and standard anastomosis to the innominate artery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The advantages of this technique are to move the distal anastomosis “forward” (i.e. away from zone 3 to zone 2 or 1), reduce the number of surgical anastomoses, and avoid surgical dissection injury to the recurrent laryngeal nerve. These serve to reduce bleeding complications, circulatory arrest time, total operative time, and post-operative morbidity. One disadvantage, however, is that all variants of this technique require endograft modification (with electrocautery or mechanical cutting). We conjecture that this could weaken the graft and predispose it to failure or endoleak. Various commercial devices have been developed to better facilitate hybrid repairs but all require standard surgical anastomosis to the head vessels. We developed this technique to capitalize on the advantages of B-SAFER (i.e. allow for endovascular revascularization of the left subclavian artery) while avoiding modification of commercially available endografts. In this patient we were able to visualize the orifice of the left subclavian artery to float a short segment of a sidearm graft and then deploy a covered stent into the left subclavian artery in antegrade fashion. Post-operative imaging indicated good seal without endoleak. This approach combines the advantages of hybrid aortic repair while minimizing any necessary endograft modification, and is a viable option for hybrid aortic repair.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTEVAR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ethoracic endovascular aortic repair\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePOD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003epost-operative day\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLSCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eleft subclavian artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVATS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evideo assisted thoracoscopic surgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eB-SAFER\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ebranched stented anastomosis frozen elephant trunk repair\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eDisclosure statement: The authors have no disclosures relevant to the publication of this work.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding statement:\u003c/h2\u003e \u003cp\u003eThe authors have no funding relevant to the publication of this work.\u003c/p\u003e \u003cp\u003eIRB: The University does not require IRB approval for publication of case reports involving one patient, however, the patient did provide written informed consent for the publication of this case report.\u003c/p\u003e \u003cp\u003eInformed Consent Statement: The patient provided written informed consent for the publication of this case report.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eCB and EJ wrote the main manuscript text. CB, OS, and FJ prepared the figures. TB, TM, and EJ provided insight into the details of writing the technique. All authors provided editorial work and reviewed the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSharaf OM, Kohtz PD, Arnaoutakis GJ. Aortic Arch Repair Using Open and Hybrid Techniques: A Systematic Review. Innovations (Phila). 2022 Jul-Aug;17(4):273\u0026ndash;282. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/15569845221115355\u003c/span\u003e\u003cspan address=\"10.1177/15569845221115355\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2022 Aug 8. PMID: 35934948.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilewski RK, Szeto WY, Pochettino A, Moser GW, Moeller P, Bavaria JE. Have hybrid procedures replaced open aortic arch reconstruction in high-risk patients? A comparative study of elective open arch debranching with endovascular stent graft placement and conventional elective open total and distal aortic arch reconstruction. J Thorac Cardiovasc Surg. 2010;140(3):590-7. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jtcvs.2010.02.055\u003c/span\u003e\u003cspan address=\"10.1016/j.jtcvs.2010.02.055\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 20723729.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoselli EE, Rafael A, Soltesz EG, Canale L, Lytle BW. Simplified frozen elephant trunk repair for acute DeBakey type I dissection. J Thorac Cardiovasc Surg. 2013;145(3 Suppl):S197-201. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jtcvs.2012.11.068\u003c/span\u003e\u003cspan address=\"10.1016/j.jtcvs.2012.11.068\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2012 Dec 20. PMID: 23260435.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoselli EE, Idrees JJ, Bakaeen FG, Tong MZ, Soltesz EG, Mick S, Johnston DR, Eagleton MJ, Menon V, Svensson LG. Evolution of Simplified Frozen Elephant Trunk Repair for Acute DeBakey Type I Dissection: Midterm Outcomes. Ann Thorac Surg. 2018;105(3):749\u0026ndash;55. Epub 2017 Dec 6. PMID: 29217087.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoselli EE, Vargo PR, Bakaeen F, Koprivanac M, Burns D, Kuramochi Y, Gillinov M, B-SAFER, Investigators. Branched stented anastomosis frozen elephant trunk repair: Early results from a physician-sponsored investigational device exemption study. J Thorac Cardiovasc Surg. 2023 Oct 5:S0022-5223(23)00895-4. doi: 10.1016/j.jtcvs.2023.09.069. Epub ahead of print. PMID: 37802330.\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":"","lastPublishedDoi":"10.21203/rs.3.rs-8264340/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8264340/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHybrid aortic repair entails a combination of open surgical and endovascular techniques. Existing techniques require modification of endografts to allow for complete arch debranching using a combination of open and endovascular techniques which may predispose the graft to failure or endoleak. We report on a novel method for hybrid aortic repair using a trifurcated graft, a collared Siena graft utilized in reversed fashion, a TEVAR stent graft, and a covered vascular graft. We demonstrate excellent seal without endoleak on the post-operative CT scan. Ultimately, this repair allows for complete arch debranching, an anastomosis in zone 2 of the aortic arch, and no endograft modification.\u003c/p\u003e","manuscriptTitle":"Florida Elephant Trunk Hybrid Aortic Repair (FETHAR): a novel frozen elephant trunk technique with complete debranching sparing endograft modification","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-03 15:43:47","doi":"10.21203/rs.3.rs-8264340/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"112272425362113959299229971507959124604","date":"2026-01-31T11:00:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248386547620751233857738839569311717906","date":"2026-01-30T09:42:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"189657591331341628665409634565814987431","date":"2026-01-29T18:58:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T10:00:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-10T03:24:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-10T03:22:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-12-02T22:13:18+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":"0c5ea9ea-9c9e-416a-beda-5725c528f650","owner":[],"postedDate":"February 3rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T16:08:24+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-03 15:43:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8264340","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8264340","identity":"rs-8264340","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}