Treatment of dissection of the aorta remains one of the great challenges in vascular surgery, but one in which steady progress has been made. In years past, even making the diagnosis was difficult, and the best means of doing so was a matter of controversy. The universal availability of high-speed and high-quality computed tomography scanning now requires only a low index of suspicion before an accurate picture of the anatomic nature of the dissection can be defined. The clinical question, therefore, no longer is What is the diagnosis? but rather What is the best course of action? As vascular surgeons, we must remember that our fundamental rules about intervention in the case of a type B dissection were built on a risk-benefit ratio calculated when options for treatment involved medical management or the performance of a very substantial operation (open fenestration or emergency thoracoabdominal aortic replacement) that favored medical management the overwhelming percentage of the time. The availability of appropriate covered stent grafts, the development of intravascular ultrasound, and the availability of hybrid imaging and operative environments helped shift the calculation of the risk-benefit ratio dramatically toward intervention. We are still trying to define the role of intervention in the treatment of this pathologic process.1Ulug P. McCaslin J.E. Stansby G. Powell J.T. Endovascular versus conventional medical treatment for uncomplicated chronic type B aortic dissection.Cochrane Database Syst Rev. 2012; 11: CD006512PubMed Google Scholar, 2Nienaber C.A. Rousseau H. Eggebrecht H. Kische S. Fattori R. Rehders T.C. et al.Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial.Circulation. 2009; 120: 2519-2528Crossref PubMed Scopus (563) Google Scholar The classic anatomic division of vascular surgery territory from cardiothoracic surgery territory just distal to the left subclavian artery has been pushed proximally in the aorta by debranching procedures and snorkel/chimney adaptations to stent grafts. In spite of this advancing level of skill set and ingenuity, the treatment of the type A aortic dissection has been firmly in the hands of the cardiac surgeons, in which only incremental advances have been made in a maximally invasive operative technique, with outcomes leaving much room for improvement. Although the postmortem deployment of a surgeon-modified graft in a flow model using a nondiseased aortic arch specimen is a preliminary study, the endovascular approach to the treatment of this pathologic process is a logical extension of the ideas and skills developed from work done on type B dissections and the transcatheter aortic valve replacement procedures. Where will this lead us? Imagination and ingenuity have forged ahead of the availability of devices that will eventually be developed as standardized approaches become adopted. Will access to the ascending aorta be transapical, as in this report, or transfemoral or even transvenous/trans-septal? The invasiveness and outcomes of the open repair of type A dissections make the endovascular approach to the treatment of ascending aortic dissection a pursuit whose time is coming. Experimental evaluation of homemade distal stent graft fenestration for thoracic endovascular aortic repair of type A dissection by a transapical approachJournal of Vascular SurgeryVol. 68Issue 4PreviewThe use of off-the-shelf stent grafts for thoracic endovascular aortic repair of type A dissections is limited by variability in both the length of the ascending aorta and the location of the proximal intimal tear. This experimental study aimed to assess the feasibility of using a physician-modified thoracic aortic stent graft to treat acute type A dissection by a transapical cardiac approach. Full-Text PDF Open Archive