Emergent Total Arch Replacement Research Articles

Utilizing a sutureless valve for prosthetic valve endocarditis after aortic root replacement

BackgroundReoperation following aortic root replacement is associated with significantly high operative mortality. Etiologies related to infection are known to increase the operative mortality rate more than other etiologies. In such a clinical setting, a sutureless valve could lower the operative mortality by shortening the cardiac arrest and the operative time.Case presentationA 61-year-old male underwent emergent aortic root and total arch replacement with an open stent graft for acute type-A aortic dissection. A bioprosthetic valve was employed for aortic root replacement using the double-sewing ring technique. A fungal infection by Candida parapsilosis was postoperatively detected and improved with intravenous antifungal drug administration. However, he developed congestive heart failure one year later, and the blood cultures turned positive repeatedly for Candida parapsilosis. The prosthetic valve infection was suspected upon identifying vegetation on the bioprosthetic valve through transthoracic echocardiography. The computed tomography scan and operative findings confirmed that the infection was localized on the prosthetic valve. Consequently, the infected valve was removed without a vascular conduit, and a sutureless valve was implanted. The postoperative course was uneventful, without any evidence of recurrent fungal infection, and the patient was discharged on postoperative day 28.ConclusionsDeploying a sutureless valve can facilitate a more straightforward and minimally invasive redo procedure. Preoperative computed tomography can predict the valve size, which is the key to implanting a sutureless valve successfully after the modified Bentall procedure.

Mycotic pulmonary artery pseudoaneurysm following total arch replacement: a case report

BackgroundAlthough the true prevalence and incidence are not clearly known, mycotic pulmonary artery aneurysm is a potentially devastating condition that leads to high mortality, over 60% if untreated. Among them, mycotic pulmonary artery pseudoaneurysm, which occurs in relatively central areas, has rarely been reported. We report an extremely rare case of a late complication with a mycotic pulmonary artery pseudoaneurysm, presumably due to infective endocarditis, in a 68-year-old woman 4 months after total arch replacement.Case presentationA 68-year-old woman was referred to our department for 2 weeks with fever of unknown origin. She had a history of emergency total arch replacement for an acute type A aortic dissection 4 months earlier and chronic rheumatoid arthritis on monthly subcutaneous tocilizumab treatment for several years. Blood culture was positive for Enterococcus faecalis. Transthoracic and transesophageal echocardiography revealed a left ventricular ejection fraction of 58%, severe mitral regurgitation with a 15-mm diameter vegetation on the anterior mitral leaflet, and severe aortic insufficiency with string-like structures. Contrast computed tomography showed a focal saccular outpouching from the right pulmonary artery. On 18F-fluorodeoxyglucose (FDG) positron emission tomography, focal uptake of FDGs was observed along the same lesion of the pulmonary artery and ascending-arch graft. The patient eventually recovered after the surgical intervention of mitral and aortic valve replacement, re-total arch replacement, pulmonary artery repair, application of omental flap, and antibiotics without any evidence of re-infection after 1 year.ConclusionsWe report a successful surgical repair of mycotic pulmonary artery pseudoaneurysm 4 months after total arch replacement for acute type A aortic dissection. This report describes an effective treatment for an extremely rare postoperative condition.

Prognostic implication of residual inflammatory trajectories in acute type I aortic dissection: dual-center prospective cohort study.

Peripheral platelet-white blood cell ratio (PWR) integrating systemic inflammatory and coagulopathic pathways is a key residual inflammatory measurement in the management of acute DeBakey type I aortic dissection (AAD); however, trajectories of PWR in AAD is poorly defined. Two AAD cohorts were included in two cardiovascular centers (2020-2022) if patients underwent emergency total arch replacement with frozen elephant trunk implantation. PWR data were collected over time at baseline and five consecutive days after surgery. Trajectory patterns of PWR were determined using the latent class mixed modelling (LCMM). Cox regression was used to determine independent risk factors. By adding PWR Trajectory, a user-friendly nomogram was developed for predicting mortality after surgery. Two hundred forty-six patients with AAD were included with a median follow-up of 26 (IRQ 20-37) months. Three trajectories of PWR were identified [cluster α 45(18.3%), β105 (42.7%), and γ 96 (39.0%)]. Cluster γ was associated with higher risk of mortality at follow-up (crude HR, 3.763; 95% CI: 1.126-12.574; P =0.031) than cluster α. By the addition of PWR trajectories, an inflammatory nomogram, composed of age, hemoglobin, estimated glomerular filtration rate, and cardiopulmonary time was developed and internally validated, with adequate discrimination [the area under the receiver-operating characteristic curve 0.765, 95% CI: 0.660-0.869)], calibration, and clinical utility. Based on PWR trajectories, three distinct clusters were identified with short-term outcomes, and longitudinal residual inflammatory shed some light to individualize treatment strategies for AAD.

Effects of Blood Hemoadsorption Therapy with HA-380 in Total Arch Replacement for Acute Type A Aortic Dissection: A Retrospective Observational Study

Introduction: This study aimed to evaluate whether the addition of a hemoadsorption (HA) cartridge, HA-380, in the cardiopulmonary bypass (CPB) circuit in acute type A aortic dissection (ATAAD) surgery reduced inflammatory cytokine levels and decreased postoperative complications. Methods: A retrospective observational cohort study was conducted between March 1, 2021, and February 28, 2022. Patients with ATAAD undergoing emergent total arch replacement surgery were divided into the control (CON) and HA groups on the basis of the addition of the HA-380 cartridge in the CPB circuit. Results: Overall, 121 patients met the eligibility criteria; 2 patients in each group who died within the first postoperative week were excluded. Further, 57 and 60 patients in the CON and HA groups, respectively, were included in the pooled analysis. The major perioperative data, baseline values of interleukin-6 (IL-6) and C-reactive protein, and therapeutic interventions were similar in the two groups (all, p > 0.05). The serum IL-6 levels increased more rapidly in the CON group than those in the HA group postoperatively (205.73 ± 174.72 vs. 146.13 ± 64.15 pg/mL, p = 0.020). The HA group had a lower incidence of postoperative acute kidney injury (AKI) and severe acute respiratory distress syndrome than the CON group (25.4 vs. 44.6%, p = 0.032 and 18.3 vs. 35.1%, p = 0.040, respectively). Logistic regression analyses showed that HA may be a protective factor against postoperative AKI. The incidence of bleeding, delirium, and stroke as well as the lengths of intensive care unit and hospital stay in both groups were similar (all, p > 0.05). Conclusions: The use of HA-380 in the CPB circuit may attenuate inflammatory response and reduce major complications following ATAAD surgery. HA may be associated with lower rate of postoperative AKI.

Mid-Term Results of Aortic Valve Sparing Root Surgery Operations

Introduction: In this study, we retrospectively analyzed the mid-term outcomes of patients who underwent aortic valve-sparing root replacement (VSARR). Patients and Methods: Ninety-six patients operated on due to annuloaortic ectasia in our clinic between 2012 and 2016 were examined. Twenty-four patients who underwent VSARR were included in the study. They were evaluated using echocardiography and computed tomography in terms of mortality and reoperation according to their preoperative demographic characteristics, aortic regurgitation (AR), and annular dilatation levels. Results: The early mortality rate was 12.5% (n= 3) and was associated with emergency operation and total arch replacement. The mean follow-up was 33.00 ± 9.53 months. The early mortality rate was 12.5% (n= 3) and was associated with emergency surgery and total arch replacement (p= 0.035, p< 0.05). The mean followup was 33.00 ± 9.53 months. None of the patients required reoperation. While postoperative AR was seen in one patient with Takayasu’s arteritis (n= 1, 4.16%), it was not observed in the patients with Marfan syndrome or bicuspid aortic valve disease. Postoperative AR and preoperative AR were related (p= 0.012, p< 0.05), but preoperative annulus diameter was not (p= 0.296, p> 0.05). There was no difference in valve durability between the use of Dacron and Valsalva grafts (p= 0.724, p> 0.05). Conclusion: For patients with aortic root aneurysms, elective VSARR is a good surgical option. However, the presence of comorbidities is related to high mortality because it necessitates urgent and complicated surgery for patients with aortic dissection.

Awake intubation for thoracic aortic aneurysm causing esophageal stenosis with food residues and compression of the pulmonary artery and left bronchi: a case report

BackgroundAnesthetic management of thoracic aortic aneurysms (TAAs) is sometimes difficult due to fatal complications, including hypovolemic shock secondary to aneurysm rupture. We report the successful management of an impending rupture of a TAA with associated esophageal stenosis and compression of the pulmonary artery and left bronchi.Case presentationAn 83-year-old woman, diagnosed with an impending rupture of the ascending TAA, was scheduled to undergo emergency total aortic arch replacement. Computed tomography showed esophageal stenosis with significant amounts of food residues in the thoracic esophagus and compression of the pulmonary artery and bronchi. We performed awake intubation and superior laryngeal nerve block with light sedation to prevent aspiration and aneurysmal rupture, respectively. General anesthesia was induced immediately after the intubation. No intraoperative complications occurred.ConclusionsPerforming awake intubation with a superior laryngeal nerve block and sedation may prevent aspiration of food residues and hemodynamic changes that may lead to rupture.

Less-Invasive Redo Total Arch Replacement With Isolated Left Vertebral Artery

A 36-year-old man with Marfan syndrome and a history of Bentall procedure was transferred to our hospital with a complaint of chest pain. Computed tomography revealed type B acute aortic dissection, with a large aneurysm of the ascending aorta (82 mm) and isolated left vertebral artery (ILVA) (Figure 1). We performed emergency total arch replacement and double-branched frozen elephant trunk (FET) surgery.1

Aortic dissection diagnosed on stroke computed tomography protocol: a case report

BackgroundAortic dissection is one of the causes of stroke. Because cerebral infarction with aortic dissection is a contraindication to intravenous recombinant tissue plasminogen activator (rt-PA) therapy, exclusion of aortic dissection is necessary prior to its administration. However, imaging takes time to provide a diagnosis, possibly causing delays in surgical treatment.Case presentationA 65-year-old Japanese female patient was transported to the hospital for a suspected stroke, with back pain and left upper and lower extremity palsy which occurred while eating. Upon arrival at the hospital, the left lower limb paralysis had improved, but the left upper limb paralysis remained. Right back pain had also developed. A plain head computed tomography (CT) scan performed 110 minutes after onset showed no acute bleeding or infarction. Subsequent CT perfusion (CTP) showed acute perfusion disturbance in the right hemisphere without infarction, known as ischemic penumbra. The four-dimensional maximum-intensity projection image reconstructed from CTP showed a delayed enhancement at the right internal carotid and right middle cerebral arteries compared to the contralateral side, suggesting a proximal vascular lesion. Contrast helical CT from the neck to abdomen revealed an acute aortic dissection of Stanford type A with false lumen patency. The dissection extended to the proximal right common carotid artery. The patient underwent an emergency total arch replacement and open stent graft. After recovering well, the patient was ambulatory upon discharge from the hospital. The combination of plain head CT, CTP, and helical CT scan from the neck to abdomen enabled us to evaluate for stroke and aortic dissection within a short amount of time, allowing for early therapeutic intervention.ConclusionsWhen acute stroke is suspected due to neurological deficits, plain head CT is the first choice for imaging diagnosis. The addition of cervical CT angiography can reliably exclude stroke due to aortic dissection. CTP can identify ischemic penumbra, which cannot be diagnosed by plain head CT or diffusion-weighted magnetic resonance imaging. These combined stroke CT protocols helped us avoid missing an aortic dissection.

Quantifying the learning curve of emergent total arch replacement in acute type A aortic dissection

BackgroundAcute type A aortic dissection with arch involvement is a life-threatening condition, which requires immediate surgical attention. Emergent total arch replacement and root reconstruction is a technically demanding operation with varying outcomes based on surgeon experience. The human factors in total arch replacement in the emergent setting have never been systematically investigated. The ability of surgeons with low volumes to achieve acceptable results in their start-up period is not known.MethodsFrom January 2013 to December 2016, patients with acute type A aortic dissection who underwent emergent total arch replacement with three surgeons were enrolled. Basic characteristics, procedural and postoperative outcomes were collected. The time of critical surgical steps and operative mortality were calculated using descriptive statistics and cumulative SUM (CUSUM) analysis.ResultsA total of 300 patients (age 53.8±11.5 years, female 63, 21.0%) with acute type A aortic dissection underwent emergent total arch replacement. A total of 219 patients (73.0%) had root reinforcement, 295 patients (98.3%) underwent frozen elephant trunk repair. Mean circulatory arrest and cross-clamp times were 29.8±9.8 and 112.3±32.1 min, respectively. The operative mortality was 6.7%, the stroke rate was 4.0%. The mean length of postoperative ICU and hospital stays were 8.4±10.6 and 18.0±12.2 days, respectively. By CUSUM depictions, surgeons appeared to have different learning curves with regards to operative time. By CUSUM failure analysis on operative mortality, two newly appointed surgeons in their start-up period stayed in an acceptable range, while one senior surgeon with higher volumes experienced superior outcomes and better performance.ConclusionsAlthough emergent total arch replacement for acute type A dissection is a complex scenario, surgeons well-trained in adult cardiac surgery are able to achieve acceptable results in their start-up period.

Successful Reversal of Delayed Postoperative Paraplegia Complicating Emergency Total Arch Replacement for Type A Dissection

Stanford A型急性大動脈解離に対する全弓部置換術後に生じた稀な合併症である遅発性対麻痺を経験した．症例は52歳男性，突然の胸背部痛のため前医に救急搬送され，Stanford A型急性大動脈解離の診断で手術目的に当院に紹介搬送となった．術前の造影CTでentryは上行大動脈に認め，遠位弓部に大きなre-entryを認めた．偽腔は開存しており，右総腸骨動脈まで広範囲の解離を認め，腹部大動脈の真腔は狭小化し右下肢の血流不全を認めた．術前の意識状態は清明で血行動態は安定しており，両下肢の運動は確認されていた．同日に緊急手術を施行した．左大腿動脈送血，右房脱血で体外循環を確立し，膀胱温26°Cの中等度低体温循環停止（最低膀胱温21.9°C），選択的脳分離体外循環下にelephant trunk法による全弓部大動脈置換術を施行した．経過は良好で，術後6時間で人工呼吸器を離脱した．平均血圧は70 mmHg前後で安定しており，呼吸器離脱前後で四肢運動が可能なことが確かめられた．術翌朝まで下肢の運動に異常は認めなかったが，術後約17時間で対麻痺が生じた．平均血圧を90 mmHg以上に保ち，緊急に脊髄ドレナージを施行し，ステロイド大量療法とナロキソンの持続点滴を併用した．脊髄ドレナージ直後から右下肢の運動が確認でき，その後のリハビリテーションにより介助なく歩行可能となり，膀胱直腸障害もなく，術後20日で独歩自宅退院となった．弓部大動脈人工血管置換術後の遅発性対麻痺は比較的稀な合併症であるが，対麻痺発症の早期診断と早期治療介入が奏功し，その重要性が示唆された．

Moderate hypothermic circulatory arrest in total arch repair for acute type A aortic dissection: clinical safety and efficacy.

Continued debates exist regarding the optimal temperature during hypothermic circulatory arrest (HCA) in aortic arch repair for patients with type A aortic dissection (TAAD). This study seeks to examine whether the use of moderate HCA in emergency aortic arch surgery provides comparable operative outcomes to deep HCA for patients with acute TAAD. We prospectively enrolled 74 consecutive patients (mean age 47.7±9.8 years, 54 males) with acute TAAD, who underwent emergency total arch replacement and frozen elephant trunk implantation under HCA (18-28 °C) with unilateral selective antegrade cerebral perfusion (uSACP). Patients were divided into two groups based on the nasopharyngeal temperature at the initiation of HCA: deep HCA (DHCA, <20 °C) in 35 (47.3%) and moderate HCA (MHCA, 20-28 °C) in 39 (52.7%). Operative outcomes including mortality, morbidity and visceral organ functions were compared between the two groups. The mean times of cardiopulmonary bypass (CPB) and aortic cross-clamp were 211±54 and 238±62 minutes (P=0.053) and 118±27 and 142±45 minutes (P=0.005) in the MHCA and DHCA groups, respectively. Operative mortality did not differ between two groups (10.2% in MHCA vs. 14.3% in DHCA groups, P=0.862). Nor did the incidence of morbidities differ between the two groups (P>0.05). The temporal trend in the changes of postoperative levels of creatinine, aspartate aminotransferase, total bilirubin and lactate did not differ between two groups (P>0.05). Multivariate analysis found that the temperature during HCA (MHCA vs. DHCA) did not affect operative mortality, morbidities and neurologic complications. Instead, CPB time (in minutes) was the risk factor for operative mortality (odds ratio, 1.032; 95% confidence interval, 1.004-1.061; P=0.023). Moderate HCA is associated with equivalent operative mortality and morbidity and visceral organ functions compared to deep HCA in patients with acute TAAD undergoing total arch replacement under uSACP. This study implies the clinical safety and efficacy of moderate HCA in emergency aortic arch repair for such patients, which provides equivalent cerebral and visceral organ protection while decreasing CPB and cross-clamp times without increasing the risk of operative mortality and morbidity.

Covered stent implantation for anastomotic pseudoaneurysm of innominate artery post total aortic arch replacement

A 59-year-old man presented with back pain that lasted 2 h. Computed tomography revealed acute type A dissection. Emergent total aortic arch replacement was performed on the same day. In 2 weeks later, CT angiography (CTA) showed the aneurysm of his innominate artery. Endovascular repair using covered stent by transbrachial artery approach was successfully performed. CTA at 8 months showed that pseudoaneurysm was excluded. The patient had no symptoms and no other complications were seen. Percutaneous endovascular therapy can be applied for high-risk patient of suprathoracic open surgery.

Emergent total arch replacement for acute type A aortic dissection with aberrant right subclavian artery in a systemic lupus erythematosus patient

A 50-year-old man with a history of systemic lupus erythematosus and hemodialysis developed acute type A aortic dissection. Computed tomography demonstrated acute type A aortic dissection with chronic distal arch aneurysm and aberrant right subclavian artery that arose from the proximal descending aorta and ran in a retro-esophageal track. Emergent total arch replacement was performed using antegrade cerebral perfusion with circulatory arrest. Both common carotid arteries and the left subclavian artery were chosen as selective cerebral perfusion sites. The right subclavian artery was snared during cerebral perfusion. The right subclavian artery was reconstructed with the right common carotid artery in an end-to-side fashion in the anterior mediastinum. The patient's postoperative course was uneventful, and computed tomography showed excellent blood flow to all four branches. The case description is followed by a discussion of cerebral protection, reconstruction route of the right aberrant subclavian artery and steroids for systemic lupus erythematosus.

Diagnosis of false lumen perfusion at the initiation of cardiopulmonary bypass using right axillary arterial perfusion during total arch replacement

To the Editor: False lumen perfusion (FP), a critical complication associated with cardiopulmonary bypass (CPB), causes organ malperfusion. Although the malperfusion mechanism associated with axillary arterial perfusion (AX-P) is not clear, elucidating the risk factors and the possible etiologies of malperfusion would aid anesthesiologists in making a rapid and accurate diagnosis. We describe a rare case of FP at the initiation of CPB using right AX-P. An 82-year-old woman diagnosed with acute type A aortic dissection underwent emergency total arch replacement. Although the aortic dissection extended from the distal ascending aorta to the abdominal aorta distal to the renal arteries, all the main branched arteries, including the three aortic arch branches, were perfused from the true lumen. Under general anesthesia, the hemodynamic status was stable (blood pressure, 80–90/ 40–50 mmHg; heart rate, 80–90 beats/min). The right and left baseline regional cerebral saturation of oxygen (rSO2) values were similar (range 70–75 %). Transesophageal echocardiography (TEE) detected to and fro movement of the intimal flap, which was synchronized with the cardiac cycle, at the entry site of the dissection on the lesser curvature on the distal aortic arch (Fig. 1a). Right AX-P with a side graft was established and full-flow CPB (cardiac index, 2.2 L/min/m) was initiated; subsequently, the inflow line pressure increased inappropriately, and the arterial blood pressure measured at the right radial artery increased to 100 mmHg. Furthermore, the pulse wave at the left index finger suddenly disappeared. TEE revealed that the intimal flap started fluttering, the entry of the aortic dissection remained open due to a deformed intimal flap (Fig. 1b), and the enlarged false lumen compressed the true lumen, indicating FP. We communicated this information to the surgeons and decided to establish femoral artery cannulation. For cerebral protection, the target body temperature was set to 24 C. After starting retrograde aortic perfusion, adequate extracorporeal perfusion was obtained. During the 37 min of FP, rSO2 did not decrease. The operation was successfully completed, without any complications associated with malperfusion of CPB. Although AX-P is associated with a lower incidence of malperfusion as compared to other sites of peripheral arterial perfusion [1, 2], the possibility of complications remains. Therefore, anesthesiologists need to check for possible malperfusion at the initiation of CPB in all patients. TEE is reportedly effective for detecting malperfusion [3]. Previously suggested mechanisms of malperfusion include the narrowing of the innominate artery [4] and FP caused by a dissection entry site involving the innominate artery [5]. The present case indicates another mechanism of malperfusion associated with right AX-P, that is, the blood flow of right AX-P via the innominate artery was directed toward the dissection’s entry site on the lesser curvature of the aortic arch, with a deformed intimal flap, resulting in FP. Thus, although this is a rare complication, anesthesiologists should recognize the risk of FP associated with right AX-P and S. Ideno (&) T. Sato M. Ueda T. Kurazumi T. Sakuma M. Nagafuchi J. Oshida Department of Anesthesiology, Saitama City Hospital, Mimuro 2460 Midori-ku, Saitama, Saitama 336-8522, Japan e-mail: doctor_idebon@yahoo.co.jp

Total Arch Replacement for Acute Aortic Dissection (Stanford A) in a Patient With Hemophilia A

As a result of improvements in medical management, patients suffering from hemophilia have a life expectancy approaching that of the normal population. An increased life expectancy, however, brings an increased risk of developing age-related disorders. Several article have reported elective cardiac operations successfully performed on hemophiliacs. To our knowledge, there are no articles describing such patients undergoing emergent aortic surgery. Our report describes the successful management of an individual with hemophilia A undergoing emergent total arch replacement for acute aortic dissection (Stanford A). We used a continuous infusion of factor VIII concentrate during the perioperative period. The patient was discharged without bleeding complications.

Infected aneurysm of the aortic arch with purulent pericarditis caused by Streptococcus pneumoniae

A 76-year-old woman had a chest pain and high fever, and was admitted to the intensive care unit diagnosed as acute pericarditis. Enhanced CT-scan showed a 47-mm aneurysm in the aortic arch which seemed to be impending rupture and the part of the aorta looked like a pseudoaneurysm. Emergent total aortic arch replacement with a rifampicin-bonded Dacron graft was performed. Pericardial effusion was purulent and the aorta was infected with pus discharge in the aortic wall. There were some ulcerations on the surface of the luminal wall of the aorta. One of them was penetrating into the pericardial space causing a pseudoaneurysm. Both pericardial effusion and excised aortic wall were sent to culture study and resulted in positive for Streptococcus pneumoniae. The infection of the aorta, with erosion into the pericardial space, seemed to be the cause of purulent pericarditis. Antibiotic therapy was commenced immediately after surgery and continued for four weeks. Though she had neurological deficit after surgery, her infection was well controlled and there was no recurrence of infection 11 months after surgery.

Closure of the Left Main Trunk of the Coronary Artery and Total Arch Replacement in Acute Type A Dissection During Coronary Angiography

A 64-year-old woman was complicated with acute type A dissection arising from the left main trunk during percutaneous coronary angiography. As the extent of dissection was localized in the ascending aorta, a bare-metal stent was inserted into the left main trunk to cover the entry of dissection. Two days after an angiography, the patient's hemodynamic status suddenly deteriorated. A computed tomographic scan showed expansion of a thrombosed false lumen severely compressing the true lumen. Emergency total arch replacement was performed, combined with ligation of the left main trunk and coronary artery bypass grafting. The patient recovered well without residual dissection in the sinus of Valsalva.

The surgical results of emergent total arch replacement in acute type A aortic dissection using new technique

Objectives: The purpose of this study was to evaluate the surgical results of integrated total arch replacement (TAR) in acute type A aortic dissection using new technique.

Emergency total aortic arch replacement for a renal transplant recipient by mild hypothermia with selective cerebral perfusion

Hypothermia and immunosuppressive drugs may promote surgical wound infection. We successfully performed an emergency total arch replacement with mild hypothermia and selective cerebral perfusion for a renal transplant recipient. The postoperative course was almost uneventful without any surgical site infection.

Is Emergency Total Arch Replacement With a Modified Elephant Trunk Technique Justified for Acute Type A Aortic Dissection?

We assess the outcome of emergency total arch replacement with a modified elephant trunk technique for acute type A aortic dissection to clarify whether our aggressive approach is justified in certain patients. Between 2000 and 2006, 54 patients (55.1% of all) underwent emergency total arch replacement for acute type A aortic dissection. The surgery was performed using open distal anastomosis with selective antegrade cerebral perfusion under hypothermia. Total arch replacement with individual arch-vessel reconstruction was applied in the following settings: the intimal tear in the transverse arch or the proximal descending aorta, massive arch dissection, Marfan syndrome, arch aneurysm, and atheromatous arch. At the distal anastomosis, a modified elephant trunk procedure was added for secure anastomosis and early thrombosed closure of the false channel in the descending aorta. Only 2 patients (3.7%) died of low cardiac output, in whom cardiac arrest had developed preoperatively owing to rupture of the arch or to left coronary artery malperfusion. There were 4 late deaths from nonaortic events. On the follow-up computed tomographic scanning, a high incidence of early thrombosed closure of the false channel in the dissected descending aorta was found. Only 2 patients, whose tear had not been resected in the first surgery, required reoperation of the descending aorta. Total arch replacement with an elephant trunk procedure, which permits immediate survival and provides early thrombosed closure of the distal false channel, is justified in certain patients with acute type A dissection.