Dr. Vincenzo Giordano: Implementation of the FET Technique in Scotland

Aortic arch diseases, such as aneurysms and dissections, represent a substantial surgical challenge due to the complexity of the anatomy and the critical nature of the surrounding vessels. Traditional surgical techniques, while life-saving, often come with high risks, especially for elderly patients or those with multiple comorbidities. With medical advancements continuing to progress, hybrid techniques like the Frozen Elephant Trunk (FET) procedure are emerging as a promising alternative.

As explained by Dr. Vincenzo Giordano, this integrates open and endovascular methods into a single operation, potentially improving long-term outcomes and reducing complications. Countries like Germany, the Netherlands, and Japan have already seen measurable success from adopting FET, offering Scotland valuable insights as it prepares to implement the technique. With focused investments in training and infrastructure, and strategic planning through pilot programs, Scotland is poised to modernize its approach to complex aortic surgery and enhance patient care across its health system.

Aortic Arch Disease and Current Practices

Aortic arch disease can lead to life-threatening complications such as stroke or organ failure if not treated effectively. It typically involves damage or degeneration of the aortic arch, the curved portion of the aorta that supplies blood to the head and upper body. This condition often requires complex surgical intervention due to the proximity to major arteries.

In Scotland, traditional open-heart surgeries remain the standard approach for many patients facing aortic arch conditions. While these methods have saved lives, they can pose higher risks for older individuals or those with additional health concerns. In many cases, prolonged recovery and hospital stays have placed additional strain on patients and healthcare systems.

Other countries have begun adopting hybrid procedures that combine open surgery with catheter-based repairs. These approaches have shown promise in reducing recovery times and improving long-term outcomes, prompting interest in expanding such methods within the healthcare system.

Exploring the Frozen Elephant Trunk (FET) Technique

The Frozen Elephant Trunk technique merges two surgical strategies into a single operation, allowing surgeons to address the aortic arch and the descending aorta in one stage. It involves placing a hybrid graft that combines a traditional surgical graft with a stent graft, enabling secure repair of complex aortic pathologies.

This is particularly useful in cases of acute type A aortic dissection, thoracic aortic aneurysms, and chronic dissections. By treating multiple sections of the aorta simultaneously, FET minimizes the need for future interventions and lowers the risk of complications. Compared to conventional methods, it offers improved long-term stability and better control of blood flow dynamics. Surgeons also report a more streamlined postoperative course for patients when the two-stage treatment is condensed into a single stage.

In many centers across Europe and Asia, FET has become a routine option for high-risk patients. Its adoption has been linked to reductions in operative mortality and neurological complications, making it an increasingly attractive option for healthcare systems looking to modernize cardiovascular care.

Why FET Matters for Scotland

Scotland faces a growing demand for advanced aortic care, particularly among aging populations with complex health profiles.

The FET technique presents an opportunity to close that gap by offering a solution that's comprehensive and adaptable. It aligns well with Scotland's broader goals of improving surgical outcomes, reducing hospital stays, and enhancing quality of life after major operations. Additionally, as healthcare systems prioritize value-based care, integrating methods that improve clinical and economic outcomes becomes critical.

Insights from Global Initiatives

Several European nations, including Germany and the Netherlands, have successfully integrated the Frozen Elephant Trunk technique into national treatment protocols. These regions report favorable outcomes, with reduced neurological complications and improved survival rates in complex aortic cases. As their experience grows, the technique is being refined and adapted to suit a myriad of patients.

In Japan, where FET has been performed extensively, long-term data support its durability and safety. Surgeons there have developed detailed procedural guidelines and have emphasized the value of early intervention. Such international developments offer Scotland a valuable roadmap for navigating its adoption process. Collaborative knowledge exchange with experienced centers could accelerate learning and minimize early implementation hurdles.

Preparing for Implementation

Adopting the FET approach requires investment in specialized surgical training and infrastructure. Surgeons must become proficient not only in traditional open techniques but also in endovascular skills. This dual competency is vital for the successful execution of hybrid procedures like FET. Hands-on workshops, simulation labs, and mentorship from experienced centers could speed up the learning curve.

Effective coordination among multidisciplinary teams—including cardiologists, anesthetists, radiologists, and intensive care specialists—will be critical. Hospitals must also ensure access to advanced imaging systems and post-operative monitoring tools to support both immediate and long-term patient care.

Considerations and Next Steps

FET in Scotland has been implemented since 2018 and has involved navigating logistical and financial challenges. The Scottish National aorto-vascular service for complex aortic surgery was established in 2001 in Edinburgh and since 2018 has been implemented with the addition of the aortic arch procedures and FET technique.

This resulted in Edinburgh becoming the referral centre for all complex procedures involving the entire aorta.

The upfront costs of new equipment and training have been significant, but the potential reduction in repeat surgeries and complications has and will offset these expenses over time. Evaluating long-term cost-effectiveness will be key to gaining stakeholder support.

Pilot programs in select hospitals could help assess feasibility and build clinical confidence. Gathering outcome data through national registries can further guide best practices and refine patient selection criteria. As momentum builds, Scotland has an opportunity to position itself at the forefront of advanced aortic care in the UK.