Secondary TEVAR After Frozen Elephant Trunk: Indications and Timing

Frozen elephant trunk (FET) stabilizes the arch and proximal descending aorta, but complete distal remodeling is achieved in only a subset of patients with aortic dissection. Persistent false lumen perfusion, aortic growth, and distal stent graft-induced new entry lead to secondary thoracic endovascular aortic repair (TEVAR), and reported distal reintervention rates range from about 13% at 5 years in pooled data to 33% in a center with routine staging. This narrative review examines the indications for and timing of secondary TEVAR after FET. PubMed was searched to September 2026, and 97 publications were included. Evidence obtained in patients treated with FET is distinguished from evidence extrapolated from primary type B dissection and from the authors’ interpretation. We summarize the predictors of incomplete remodeling, including stent graft length, residual re-entry location, chronicity, aortic diameter at the distal stent level, early remodeling trajectory, and heritable aortopathy, and we contrast planned completion with surveillance-based reactive TEVAR, including technical aspects and spinal cord protection. Direct evidence on timing after FET is limited to retrospective series and one pilot randomized trial of TEVAR 1 to 3 months after type I repair; most data on the time-dependent loss of flap plasticity come from primary type B dissection. No universal timing rule is supported. We propose a phenotype-driven approach, not yet validated, in which timing is referenced to dissection onset and individualized to aortic anatomy, disease progression, and clinical condition.