Evolution of the FET
Started as “Essen I Prosthesis”, the hybrid prosthesis was first commercially available as Evita Open (Jotec®, Hechingen, Germany) in 2005 [3]. With the non-availability of the hybrid prosthesis in USA, surgeons have explored different options - antegrade delivery of a stent graft during deep hypothermic circulatory arrest (DHCA)[4] or by creating a scallop in the endoprosthesis to accommodate the supra aortic arch vessels [5]. A major concern of FET was the higher incidence of paraplegia compared to the classical elephant trunk. This prompted the surgeons to reduce the length of the stent-graft and / or proximalize the distal anastomosis from zone 3 to zone 2 [6]. This further paved the way for technical advancements wherein surgeons introduced a fenestration of the stent graft for the left subclavian artery (LSA) [7] or a side branch to the LSA in the hybrid prosthesis. Sometimes, surgical efforts to reimplant the very distal and posterior left subclavian artery included the intra-thoracic aortic-subclavian bypass, aortic-axillary bypass and extra-thoracic carotid-subclavian bypass [8]. This warrants an additional incision in the left infraclavicular or supraclavicular region. These advancements entails the adjustments of the extracorporeal circuit [6].Though with the advancements, the FET still requires DHCA with selective antegrade cerebral circulation (SACP), restricting the procedure to be performed by surgeons familiar with aortic arch surgery. To overcome this, newer technical devices developed by JOTEC/CryoLife, Kennesaw, USA are being introduced aiming to reduce complexity enabling surgeons to perform FET in zone 0 or 1 as opposed to zone 3 (Fig.1)