Frozen elephant trunk (FET) has in recent times become a mainstay for total arch replacement (TAR) in aortovascular surgery and is indicated in order to treat a spectrum of complex aortic pathologies. However, despite associated excellent post-operative results it is incredibly important to recognise potential adverse complications such as negative aortic remodelling, endoleak and distal stent-graft induced new entry so that outcomes can be further improved. Below we provide commentary on a recent article in the Journal of Cardiac Surgery discussing the topic. Despite the fascinating outcomes of this systematic review and meta-analysis the heterogeneity of the literature regarding these adverse outcomes remains an issue which can only be solved with large multi-centre trials directly comparing graft types as well as indications for surgery.