Technical aspects of total aortic repair in the surgical management of acute type A aortic dissection

Abstract

Traditional surgical techniques for the management of acute type A aortic dissection (ATAAD) focus on open distal anastomosis with or without hemiarch replacement under a period of deep hypothermic circulatory arrest. This is associated with high rates of false lumen (FL) patency, which exposes the patient to the risk of ongoing end-organ malperfusion and to the formation of complex arch and thoracoabdominal dissection aneurysms. Furthermore, persistent malperfusion is a major source of morbidity and mortality and is not easily reversed following traditional central repair. Arch replacement using the “branch first” technique allows for complete root, ascending and arch replacement (1-3). A long landing zone is created for proximal endografting with a covered stent. Extended thoracoabdominal stenting is performed in patients with: Ongoing or recurrent branch vessel ischaemia or malperfusion; Radiological true lumen (TL) collapse; Rapid dilatation of the FL; Markers of compromised TL perfusion. The following video (Video 1) illustrates a case of TAAD with clinical and radiological malperfusion and shows the benefits of “branch first” arch replacement followed by stent grafting in this situation. Video 1 Technical aspects of total aortic repair in the surgical management of acute type A aortic dissection.