Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Abstract

Three-dimensional American Heart Association Contrast enhanced Cardiopulmonary bypass Clinical prediction models Cerebrospinal fluid Computed tomography Computed tomography angiography Descending thoracic aorta European Association for Cardio-Thoracic Surgery Electrocardiography Electroencephalography European Society of Cardiology European Society for Vascular Surgery Elephant trunk Femoral artery Frozen elephant trunk Giant cell arteritis Gadolinium Haemoglobin Hypothermic circulatory arrest Innominate artery Intramural haematoma Loeys–Dietz syndrome Left subclavian artery Motor evoked potentials Marfan syndrome Multiplanar reconstruction Magnetic resonance angiography Magnetic resonance imaging Near-infrared spectroscopy Penetrating aortic ulcer Positron emission tomography Parallel graft Regional cerebral oxygen saturation Selective antegrade cerebral perfusion Spinal cord injury Somatosensory evoked potentials Society of Thoracic Surgeons Society of Thoracic Surgeons Predicted Risk of Mortality Thoraco-abdominal Thoracic aortic aneurysm Thoracic/Thoraco-abdominal aortic aneurysm Total arch replacement Transoesophageal echocardiography Thoracic endovascular aortic repair Unfractionated heparin Ultrasound Writing committee The last decade has substantially broadened treatment options for patients with thoracic aortic pathology involving the aortic arch. Traditionally, treatment of aortic arch pathology was a domain of open cardiac surgery. The advent of combined vascular and endovascular procedures opened a new field thereby enabling treatment in previously operated on and in less fit patients. As a subsequent technological leap, branched arch stent grafts became available and are currently gaining acceptance in the community. Also, open surgery has substantially improved, and the increased use of right subclavian artery cannulation and selective antegrade cerebral perfusion (SACP) at warmer lower body circulatory arrest times together with improved monitoring of organ function has substantially contributed to excellent results in these still major operations. Still, neurological complications remain a major concern of all procedures addressing aortic arch pathology irrespective if open surgery or endovascular repair. The reduction of neurological complications to a minimum will be one of the major tasks of the future. Cross linking between cardiac and vascular surgery has amplified knowledge. Interestingly enough, although dividing cardiac and vascular surgery into separate units was popular for a time, in many institutions they are being combined again to create aortic centres, a trend which should be interpreted as a plea to work together without creating borders between specialties. Our hope is that, in the future, treatment portfolios will be designed by a single group of people working together to understand the natural course of the disease where physicians are doing the right things when it comes to treatment and the entire aortic team follows an anticipative strategy to remain ahead of the disease process. The purpose of this combined effort of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society for Vascular Surgery (ESVS) was to develop an expert consensus document covering all aspects of aortic arch disease and to provide the community with a pragmatic guide to understand the natural history of the various disease processes, to aid in indicating treatment and to provide support in choosing the right treatment modality in the right patient at the right point in time. Finally, this document aims to harmonize terminology in acute and chronic proximal thoracic aortic pathology. The recommendation grade indicates the strength of a recommendation. Definitions of the classes of recommendations and levels of evidence are shown in Table 1, Table 2.Table 1Classes of recommendations. Open table in a new tab Table 2Levels of evidence.Level of evidence AData derived from multiple randomized clinical trials or meta-analyses.Level of evidence BData derived from a single randomized clinical trial or large non-randomized studies.Level of evidence CThe consensus of expert opinion and/or small studies, retrospective studies, registries. Open table in a new tab The Writing Committee (WC) refers to and recommends the use of the definition of attachment zones as provided by ‘Reporting standards for thoracic endovascular aortic repair’, which are also known as ‘Ishimaru zones’ in the aortic arch1Fillinger M.F. Greenberg R.K. McKinsey J.F. Chaikof E.L. Society for vascular surgery Ad Hoc committee on TEVAR reporting standards. Reporting standards for thoracic endovascular aortic repair (TEVAR).J Vasc Surg. 2010; 52: 1022-1033Abstract Full Text Full Text PDF PubMed Scopus (277) Google Scholar (Fig. 1). Regarding anatomical characteristics of the aortic arch, we refer to the classifications of type I, type II and type III aortic arch configurations.2Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey D.E. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.Circulation. 2010; 12: e266-e369Google Scholar There are 3 types of aortic arches, and they are based on the relationship of the innominate artery (IA) to the aortic arch.3Casserly I.P. Yadav J.S. Carotid intervention.in: Casserly I.P. Sachar R. Yadav J.S. Manual of peripheral vascular intervention. Lippincott Williams & Wilkins, Philadelphia, PA2005: 83-109Google Scholar In a type I aortic arch, all 3 great vessels originate in the same horizontal plane as the outer curvature of the aortic arch. In a type II aortic arch, the IA originates between the horizontal planes of the outer and inner curvatures of the aortic arch. In a type III aortic arch, the IA originates below the horizontal plane of the inner curvature of the aortic arch (Fig. 2). Regarding the use of descriptive terms of specific arch configurations such as gothic arch, steep arch angulation and aortic arch radius, no least common denominator could be identified to add a meaningful definition. Therefore, the use of these terms to describe a specific morphology remains subjective. The WC suggests that the terms ‘multiple entries and re-entries’ be removed from clinical use and be replaced by the wording ‘most proximal tear’, ‘communications between lumina’ and ‘most distal tear’ in addition to the term ‘primary entry tear’. This proposed wording should help create a better understanding of the pathophysiology as well as help standardize communication between physicians describing the pathology. The WC suggests use of the term ‘acute’ for any dissection between the onset of symptoms and 14 days, ‘subacute’ between 15 days and 90 days and ‘chronic’ thereafter. The WC refers to the original proposal from Stanford that defines type A aortic dissection as any dissection involving the ascending aorta but refers to type B aortic dissection when only the descending thoracic aorta (DTA) is involved. Arch involvement either by the most proximal tear or by retrograde extension is referred to as non-A-non-B aortic dissection. The WC uses the wording of the ESVS clinical practice guidelines on the management of DTA diseases, which define complicated type B aortic dissection as ‘the presence of rapid aortic expansion, aortic rupture and/or hypotension/shock, visceral, renal or limb malperfusion, paraplegia/paraparesis (spinal malperfusion), periaortic haematoma, recurrent or refractory pain and refractory hypertension despite adequate medical therapy’.4Riambau V. Böckler D. Brunkwall J. Cao P. Chiesa R. Coppi G. et al.Management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2017; 53: 4-52Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar The WC also applies this wording for complications in acute type A as well as in acute non-A-non-B aortic dissection and adds pericardial tamponade, acute aortic valve regurgitation, coronary and cerebral malperfusion to the one with either type A or non-A-non-B aortic dissection.5Czerny M. Schoenhoff F. Etz C. Englberger L. Khaladj N. Zierer A. et al.The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: results from the GERAADA registry.J Am Coll Cardiol. 2015; 65: 2628-2635Crossref PubMed Scopus (83) Google Scholar When referring to aortic arch treatment, qualitative and semiquantitative statements should be avoided. Given the rising number of patients receiving open and endovascular therapy, it seems reasonable to refer to the treatment-based classification using the terminology ‘zones 0–4’ when describing surgery on the aortic arch. Again, ‘distal arch aneurysm’ covers a wide range of anatomical variations. Replacing the arch using a frozen elephant trunk (FET) with an anastomosis proximal to the left carotid artery and selective reimplantation using separate grafts is not adequately covered in the current definitions. One notable exception is the term ‘hemiarch’, which has been widely used for decades even if it also covers a wide range of surgical strategies from just replacing the ascending aorta and performing an open distal anastomosis to resecting the entire concavity of the arch down to the proximal DTA. For the purpose of this paper, total arch replacement (TAR) is defined as replacing the entire aortic arch—or excluding it from circulation as is the case when using the FET technique—from the offspring of the IA to a point beyond the offspring of the left subclavian artery (LSA). Reimplantation or revascularization of the supra-aortic branches can be performed in many ways, and the method used is not part of the definition of TAR. To facilitate communication and to harmonize the standards of reporting, defining TAR as replacing (or excluding from circulation) aortic zones 0–2 (or beyond) seems reasonable. All other procedures on the arch should be named partial arch replacement. The chronic dissected state of aortic segments distal to the proximal repair is defined as ‘residual dissection after type A repair’. The WC refers to chimneys, snorkels and periscopes using the term ‘parallel grafts’. The WC advocates that an aortic team should be closely involved from diagnosis to treatment and finally follow-up and should be led by members from cardiac and vascular surgery in collaboration with anaesthesiology, cardiology, radiology and genetics. A major advantage of surgery as the leading specialty is that surgeons have experience linking radiographic findings to tissue quality, which is a major component when opting for open surgery or endovascular treatment. Additionally, centralization of care of aortic arch pathologies in large centres is recommended because it is the only way to effectively understand the natural course of the disease, provide the entire range of treatment options under one umbrella and treat potential complications of each individual therapy.6Czerny M. Bachet J. Bavaria J. Bonser R.S. Borger M.A. De Paulis R. et al.The future of aortic surgery in Europe.Eur J Cardiothorac Surg. 2013; 43: 226-230Crossref PubMed Google Scholar A streamlined emergent care pathway (24/7 availability without diversion), adequate transportation and transfer capabilities as well as rapid activation of the multidisciplinary team must be available. There is growing evidence that there is a clear correlation between numbers and outcome in aortic medicine.7Andersen N.D. Ganapathi A.M. Hanna J.M. Williams J.B. Gaca J.G. Hughes G.C. Outcomes of acute type A dissection repair before and after implementation of a multidisciplinary thoracic aortic surgery program.J Am Coll Cardiol. 2014; 63: 1796-1803Crossref PubMed Scopus (71) Google Scholar, 8Miyata H. Motomura N. Ueda Y. Tsukihara H. Tabayashi K. Takamoto S. Toward quality improvement of thoracic aortic surgery: estimating volume-outcome effect from nationwide survey.Eur J Cardiothorac Surg. 2009; 36: 517-521Crossref PubMed Scopus (26) Google Scholar, 9Henebiens M. van den Broek T.A.A. Vahl A.C. Koelemay M.J.W. Relation between hospital volume and outcome of elective surgery for abdominal aortic aneurysm: a systematic review.Eur J Vasc Endovasc Surg. 2007; 33: 285-292Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 10Cowan J.A. Dimick J.B. Henke P.K. Huber T.S. Stanley J.C. Upchurch G.R. Surgical treatment of intact thoracoabdominal aortic aneurysms in the United States: hospital and surgeon volume-related outcomes.J Vasc Surg. 2003; 37: 1169-1174Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar, 11Schaffer J.M. Lingala B. Miller D.C. Woo Y.J. Mitchell R.S. Dake M.D. Midterm survival after thoracic endovascular aortic repair in more than 10,000 Medicare patients.J Thorac Cardiovasc Surg. 2015; 149 (discussion 820–3): 808-820Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 12Badheka A.O. Patel N.J. Panaich S.S. Patel S.V. Jhamnani S. Singh V. et al.Effect of hospital volume on outcomes of transcatheter aortic valve implantation.Am J Cardiol. 2015; 116: 587-594Abstract Full Text Full Text PDF PubMed Google Scholar With regard to imaging, it is clear that the ability to obtain a hybrid-room setting is limited in many hospitals. However, few trade-offs should be made because adequate intraoperative imaging forms the basis of reliable delivery of quality. Finally, a structured surveillance of all patients, either before they reach the criteria for treatment or after treatment, is strongly emphasized. One reason is quality control; another is the potential to develop aortic pathology in non-treated upstream or downstream aortic segments.Tabled 1Recommendation 1Decision making for the treatment of aortic arch pathologies by an aortic team is recommendedClassLevelReferencesIC- Open table in a new tab Tabled 1Recommendation 2Centralization of care for aortic arch pathologies is recommendedClassLevelReferencesIC- Open table in a new tab Tabled 1Recommendation 3Treatment of elective aortic arch pathology is recommended to be performed in specialized centres providing open and endovascular cardiac and vascular surgery on site onlyClassLevelReferencesIC- Open table in a new tab Tabled 1Recommendation 4Continuing follow-up of patients with aortic arch pathologies before and after treatment in a dedicated outpatient clinic is recommendedClassLevelReferencesIC- Open table in a new tab Tabled 1Recommendation 5A hybrid room with a fixed imaging system is recommended for thoracic endovascular aortic repair involving the aortic archClassLevelReferencesIC- Open table in a new tab The vast majority of aortic arch pathologies are based on either aneurysm formation or dissection. Although dissection on the basis of previous aneurysm formation is rare, it is the main driver for accelerated growth during follow-up. An isolated aneurysm of the aortic arch is rare, and most arch aneurysms that ultimately lead to surgical intervention are caused by aneurysms or dissections of either the ascending or the DTA, which at some point extend into the arch or by penetrating aortic ulcers (PAU). Population-based studies have shown that 60% of thoracic aortic aneurysms (TAA) occur in the root or the ascending aorta, 40% in the DTA and 10% include the aortic arch with some extending into more than 1 thoracic aortic segment.13Isselbacher E.M. Thoracic and abdominal aortic aneurysms.Circulation. 2005; 111: 816-828Crossref PubMed Scopus (472) Google Scholar There is no controlled trial that specifically looked at the natural history of aortic arch disease. Several papers discussing the fate of the aortic arch do so by almost exclusively citing data that were derived from either observations on the ascending or the DTA. Moreover, contemporary observational studies and registries are heavily biased by the fact that many patients with aneurysm diameters exceeding the threshold for surgery recommended by the current guidelines do in fact undergo surgery.14Pape L.A. Tsai T.T. Isselbacher E.M. Oh J.K. O'Gara P.T. Evangelista A. et al.Aortic diameter >or = 5.5 cm is not a good predictor of type A aortic dissection: observations from the International Registry of Acute Aortic Dissection (IRAD).Circulation. 2007; 116: 1120-1127Crossref PubMed Scopus (365) Google Scholar Therefore, there is a tendency towards facing dissection in patients with smaller diameters that had not yet reached the threshold for surgery. Conversely, some patients present with large aneurysms that exceed by far the current recommendations for surgery but have not yet dissected. Most papers dealing with aortic diameters and risk for dissection base their conclusions on post-dissection diameters. Due to the formation of intra- and periaortic haematomas, measuring the post-dissection diameter is not reliable. A study looking at patients with acute type A dissection who for some reason previously underwent imaging of the aorta has shown that the aortic diameter increases by about 30% at the time of dissection.15Rylski B. Branchetti E. Bavaria J.E. Vallabhajosyula P. Szeto W.Y. Milewski R.K. et al.Modeling of predissection aortic size in acute type A dissection: more than 90% fail to meet the guidelines for elective ascending replacement.J Thorac Cardiovasc Surg. 2014; 148: 944-948Abstract Full Text Full Text PDF PubMed Google Scholar This clearly indicates that diameter at the time of presentation itself is not the sole predictor of the risk of dissection. The 2010 American Heart Association (AHA)2Hiratzka L.F. Bakris G.L. Beckman J.A. Bersin R.M. Carr V.F. Casey D.E. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine.Circulation. 2010; 12: e266-e369Google Scholar and 2014 European Society for Cardiology (ESC)16Erbel R. Aboyans V. Boileau C. Bossone E. Bartolomeo R.D. Eggebrecht H. et al.2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (1389) Google Scholar guidelines refer to various publications that focused on interventions in arch aneurysms or dissections, especially regarding hybrid procedures, but the 2014 ESC guidelines do not cite a single paper on the natural history of the arch aneurysm, and the 2010 AHA guidelines refer only to the 1997 paper from the Yale cohort.17Coady M.A. Rizzo J.A. Hammond G.L. Mandapati D. Darr U. Kopf G.S. et al.What is the appropriate size criterion for resection of thoracic aortic aneurysms?.J Thorac Cardiovasc Surg. 1997; 113: 476-491Abstract Full Text Full Text PDF PubMed Scopus (354) Google Scholar Data from the Yale aortic database have demonstrated an average annual growth rate of 1 mm for ascending aortic aneurysms and 2.9 mm for descending aortic aneurysms. Nevertheless, growth rates vary according to the underlying disease and the absolute size of the aneurysm. Larger aneurysms tend to grow faster. It is important to realize that 95% of patients with TAA are asymptomatic until the first event. Calculating the risk for dissection or rupture is difficult, but a large study including 721 patients with TAA demonstrated an annual risk for dissection or rupture of 6.9% in patients with an aneurysm diameter greater than 60 mm. The 5- year survival rate in patients with TAA not undergoing intervention was only 54%.18Davies R.R. Goldstein L.J. Coady M.A. Tittle S.L. Rizzo J.A. Kopf G.S. et al.Yearly rupture or dissection rates for thoracic aortic aneurysms: simple prediction based on size.Ann Thorac Surg. 2002; 73 (discussion 27–8): 17-27Abstract Full Text Full Text PDF PubMed Scopus (581) Google Scholar, 19Kuzmik G.A. Sang A.X. Elefteriades J.A. Natural history of thoracic aortic aneurysms.J Vasc Surg. 2012; 56: 565-571Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar There are only a few reports that focus specifically on the aortic arch. In a small study including 45 patients over a 14-year period with a mean follow-up of 37 months, the average annual growth rate was 2.5 mm per year but varied widely between 0 and 16 mm. During the study period, 22% of patients suffered from a rupture. The authors calculated that aneurysms with an annual growth rate of >5.5 mm per year have a 67% likelihood of rupture compared with 8.3% in patients with a growth rate of <5.5 mm per year. Furthermore, in their study, an aneurysm size >6.5 cm and hyperlipidaemia correlated with more rapid expansion. In a multivariate analysis, growth rate was the sole independent risk factor for aneurysm rupture (OR 1.43; 95% confidence interval, 1.06–1.92; P = 0.018).20Yiu R.S. Cheng S.W.K. Natural history and risk factors for rupture of thoracic aortic arch aneurysms.J Vasc Surg. 2016; 63: 1189-1194Abstract Full Text Full Text PDF PubMed Google Scholar Although the current evidence is minimal, there seems to be no justification to conduct a prospective randomized trial comparing natural history to treatment. It has been shown that 21% of patients with TAA have a relative with an already known aneurysm and that patients with familial occurrence of TAA have aneurysms that grow faster than those in patients with sporadic forms (2.1 mm per year vs 1.6 mm per year; ascending and DTA combined).21Albornoz G. Coady M.A. Roberts M. Davies R.R. Tranquilli M. Rizzo J.A. et al.Familial thoracic aortic aneurysms and dissections—incidence, modes of inheritance, and phenotypic patterns.Ann Thorac Surg. 2006; 82: 1400-1405Abstract Full Text Full Text PDF PubMed Scopus (245) Google Scholar This is an important aspect of thoracic aortic disease, and rapid progress is currently being made in identifying genetic mutations causing TAA. Over the past decade, the medical community has slowly accepted the idea that patients presenting with aortic aneurysm and/or dissection are part of a wide spectrum of genetically mediated diseases that present in syndromic as well as non-syndromic forms. Marfan syndrome (MFS) has long been the only seriously considered differential diagnosis in terms of a heritable disorder of connective tissue in patients with an aortic aneurysm. It has been shown that aneurysm formation in MFS is driven by excessive levels of transforming growth factor-b, a ubiquitous cytokine in most mammalian cells that is involved in cellular proliferation and differentiation. Loeys and Dietz identified a subset of patients sharing certain features such as a bifid uvula, hypertelorism and marked tortuosity of the vessels that had not been typically associated with MFS. The group identified mutations in the gene encoding for the transforming growth factor-b receptors 1 and 2 as the causative mutation.22Loeys B.L. Chen J. Neptune E.R. Judge D.P. Podowski M. Holm T. et al.A syndrome of altered cardiovascular, craniofacial, neurocognitive and skeletal development caused by mutations in TGFBR1 or TGFBR2.Nat Genet. 2005; 37: 275-281Crossref PubMed Scopus (1083) Google Scholar, 23Loeys B.L. Schwarze U. Holm T. Callewaert B.L. Thomas G.H. Pannu H. et al.Aneurysm syndromes caused by mutations in the TGF-beta receptor.N Engl J Med. 2006; 355: 788-798Crossref PubMed Scopus (1020) Google Scholar Identifying Loeys–Dietz syndrome (LDS) as a separate entity was important because patients with LDS suffered from acute aortic dissection at aortic diameters that had not been considered a cut-off to proceed to surgery in patients with MFS. Meanwhile several different mutations in patients within the spectrum of LDS have been identified. Preliminary data suggest significant differences in the risk of acute dissection in these patients. Data from the Johns Hopkins group showed that a significant number of LDS patients had to undergo interventions on the aortic arch after elective root replacement, something that has been rarely seen in Marfan patients. With the advent of high-throughput sequencing techniques, more and more causative mutations in non-syndromic forms of type A aortic dissection have been identified. It has been shown that 11–19% of patients without (known) genetic defects have a first-degree relative with type A aortic dissection. Identifying the causative mutation in patients presenting with type A aortic dissection has a direct impact on the indication for surgery, the extent of surgery, and the prognosis of the patient and of his or her relatives. According to the Stanford classification of aortic dissection, a dissection is considered to be a type A dissection if the ascending aorta is involved, regardless of the location of the primary entry tear. According to this definition, a dissection in the aortic arch is generally considered a type B dissection. But as 90% of the type B dissections occur distally to the LSA, the majority of data on type B dissection does not apply to aortic arch dissection.4Riambau V. Böckler D. Brunkwall J. Cao P. Chiesa R. Coppi G. et al.Management of descending thoracic aorta diseases: clinical practice guidelines of the European Society for Vascular Surgery (ESVS).Eur J Vasc Endovasc Surg. 2017; 53: 4-52Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar Nevertheless, the notion of ‘non-A-non-B′ dissections needs to be established (Fig. 3). Some studies have implicated anatomical variants as predisposing factors for dissections with entries in the aortic arch. In a study including 157 patients24Dumfarth J. Plaikner M. Krapf C. Bonaros N. Semsroth S. Rizzo J.A. et al.Bovine aortic arch: predictor of entry site and risk factor for neurologic injury in acute type A dissection.Ann Thorac Surg. 2014; 98: 1339-1346Abstract Full Text Full Text PDF PubMed Google Scholar who underwent surgery for acute type A aortic dissection, 14% of the patients had either a common origin of the IA and the left common carotid artery (LCCA) or an origin of the LCCA from the IA, and the rate of arch entries in this group was significantly higher compared to that in patients without this pattern (59% vs 13%, P < 0.001). Furthermore, the presence of this arch pattern was associated with a higher rate of postoperative neurological injury (odds ratio 4.9, 95% confidence interval 1.635–14.734; P = 0.005). The fate of the aortic arch in patients with type A aortic dissection is strongly correlated with the extent of the initial surgery. It has been clearly shown that not replacing the entire ascending aorta results in a high rate of reoperations. Therefore, performing at least a primary entry tear-oriented hemiarch replacement is recommended. The additional burden of replacing the entire aortic arch as an adjunct to elective or emergent proximal repair is not very well defined and makes comparison with patients undergoing secondary TAR difficult. Most papers reporting on outcomes after surgery for type A dissection or those dealing with reintervention after proximal repair do not discuss arch-related morbidity and mortality separately.25Kobuch R. Hilker M. Rupprecht L. Hirt S. Keyser A. Puehler T. et al.Late reoperations after repaired acute type A aortic dissection.J Thorac Cardiovasc Surg. 2012; 144: 300-307Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 26Concistrè G. Casali G. Santaniello E. Montalto A. Fiorani B. Dell'Aquila A. et al.Reoperation after surgical correction of acute type A aortic dissection: risk factor analysis.Ann Thorac Surg. 2012; 93: 450-455Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar The major risk factor for the need of reintervention on the aortic arch and distal aorta after repaired type A dissection is a patent false lumen. Furthermore, pseudoaneurysm or dehiscence at the level of the distal anastomosis has been described as a frequent cause for reoperation. Therefore, several groups began to advocate TAR and implantation of an FET in addition to proximal repair in type A dissection. Interestingly, Asian groups tend to favour a more aggressive approach and mostly recommend TAR during initial surgery for type A dissection. It has been discussed whether this is also due to a more favourable anatomy in the Asian population and a more pronounced atherosclerotic burden in Western countries, which increases the risk for stroke during TAR. In 2009, a Japanese group published one of the very few reports c