Background: Our aim was to investigate outcomes and long-term survival in male and female patients after frozen elephant trunk (FET) total arch replacement. Methods: Between March 2013 and January 2023, 362 patients underwent aortic arch replacement via the FET technique. We compared patient characteristics and intra- and postoperative data between male and female patients. Results: Male patients were significantly younger (p = 0.012) but revealed a higher incidence of coronary artery disease (p = 0.008) and preoperative dialysis (p = 0.017). More male patients presented with type A aortic dissections (p = 0.042) while more female patients had aortic aneurysms (p = 0.025). The aortic root was replaced in significantly more male patients (p = 0.013), resulting in significantly longer cardiopulmonary bypass duration (p < 0.001) and operative times (p < 0.001). There were no statistically significant differences in postoperative outcome parameters including in-hospital mortality (p = 0.346). However, new in-stent thrombus formation was significantly more frequent in female patients (p = 0.002). Age in years (odds ratio (OR): 1.026, p = 0.049), an acute pathology (OR: 1.941, p = 0.031) and preoperative dialyses (OR: 3.499, p = 0.010) were predictive for long-term mortality in our Cox regression model, sex (p = 0.466) was not. There was no statistical difference in overall survival (log rank: p = 0.425). Conclusions: Female patients are older but reveal fewer cardiovascular risk factors; aneurysms are more common in female than male patients. As female patients undergo concomitant surgical procedures less often, their operative times are shorter. While survival and outcomes were similar, female patients suffered from postoperative new in-stent thrombus formation significantly more often.

Background and objectives: The treatment of pathologies of the aortic arch is a complex field of cardiovascular surgery that has witnessed enormous progress recently. Such treatment is mainly performed in high-volume centres, and surgeons gain great experience in mastering potential difficulties even under emergency circumstances, thereby ensuring the effective therapy of more complex pathologies with lower complication rates. As the numbers of patients rise, so does the need for well-trained surgeons in aortic arch surgery. But how is it possible to learn surgical procedures in a responsible way that, in addition to surgical techniques, also places particular demands on the overall surgical management such as perfusion strategy and neuro-protection? This is why a good training programme teaching young surgeons without increasing the risk for patients is indispensable. Our intention was to highlight the most challenging aspects of aortic arch surgery teaching and how young surgeons can master them. Materials and Methods: We analysed the literature to find out which methods are most suitable for such teaching goals and what result they reveal when serving as teaching procedures. Results: Several studies were found comparing the surgical outcome of young trainees with that of specialists. It was found that the results were comparable whether the procedure was performed by a specialist or by a trainee assisted by the specialist. Conclusions: We thus came to the conclusion that even for such a complex type of intervention, the responsible training of young surgeons by experienced specialists is possible. However, it requires a clear strategy and team approach to ensure a safe outcome for the patient.

Background and Objectives: This study aimed to evaluate the impact of body mass index (BMI) on post- operative outcomes in patients undergoing aortic arch repair with the frozen elephant trunk technique (FET). Materials and Methods: A total of 387 patients who underwent an FET procedure between 04/2014 and 11/2024 were retrospectively analyzed. Patients were divided into four groups according to BMI: underweight (BMI < 18.5, n = 12) normal weight (BMI: 18.5 to <25, n = 150), overweight (BMI: 25 to <30, n = 154), and obese (BMI: ≥30, n = 71). Patient characteristics and clinical outcomes were compared across groups. Multivariable Cox regression, interaction analysis, and restricted cubic spline modelling were performed using R (Version 4.4.3). Results: Interaction analysis revealed BMI-dependent effect modification for several predictors. Insulin-dependent diabetes mellitus was associated with increased mortality only in patients with BMI < 25 kg/m² (interaction p = 0.003). Transfusion of packed red blood cells (PRBCs) also showed a significant interaction with BMI (p = 0.016), with a stronger effect in patients with BMI < 25 kg/m², although significant in both strata. Moreover, cross-clamp time demonstrated a BMI-dependent interaction (p = 0.047), with numerically higher mortality hazards in overweight patients (BMI > 25 kg/m²), but without statistically significant subgroup effects. Spline analysis indicated a non-linear, threshold-based association between overall mortality and BMI but does not reach statistical significance. Kaplan–Meier analysis showed no significant difference in 5-year survival among BMI categories. Conclusions: BMI should not be used as a primary risk stratification tool for survival after an FET procedure. Rather, attention should be paid to comorbid conditions and intraoperative factors that interact with BMI. For patients with lower BMI (25 kg/m²). Future studies should aim to clarify the impact of BMI on outcomes after FET, particularly in the context of patient selection and perioperative optimization strategies.