Total Arch Replacement For Type Research Articles

Comparison of Partial Upper Sternotomy Versus Median Sternotomy for Total Arch Replacement in Patients With Type A Aortic Dissection

Objective: Comparative studies of median sternotomy and partial upper sternotomy in total arch replacement for type A aortic dissection are rare, and the safety and benefits of partial upper sternotomy need further evaluation. This study aimed to explore the effectiveness and prognosis of partial upper sternotomy in total arch replacement among patients with type A aortic dissection. Methods: This is a retrospective study of patients who underwent total arch replacement for type A aortic dissection at the First Medical Center of Chinese People’s Liberation Army General Hospital between January 2016 and December 2019. They were grouped into the median sternotomy and partial upper sternotomy groups according to the different treatment methodologies. The intra-operative and prognostic indicators were compared between both groups. Results: Forty-nine patients were included: 31 in the median sternotomy group and 18 in the partial upper sternotomy group. The partial upper sternotomy group had a shorter incision ((9.0 ± 0.8) cm vs. (25.5 ± 1.3) cm, P = 0.02) and smaller postoperative total drainage volume (885 mL vs. 1,820 mL, P = 0.03) than the median sternotomy group. The differences between the 2 groups with respect to other intra-operative indicators such as operation duration, cardiopulmonary bypass duration, aortic occlusion duration, hypothermic circulatory arrest duration, and intra-operative blood loss, and prognostic indicators such as red blood cell infusion, ventilator aid duration, cardiac intensive care unit stay, postoperative hospital stay, and postoperative complications were not significantly different (all P > 0.05). Conclusions: The utilization of partial upper sternotomy in patients with type A aortic dissection resulted in a smaller incision and more aesthetically pleasing scar, along with reduced drainage volume compared to median sternotomy.

Rare complication: refractory hypertension and intermittent claudication caused by elephant trunk entrapped in a new entry after total arch replacement for type A aortic dissection

BackgroundTotal arch replacement using elephant trunk (ET) has been accepted as a standard technique for thoracic aortic dissection. However, there are few complications related to the ET, such as kinking of the ET, paraplegia, splitting of the anastomosis, and thromboembolic complications. We report a successful thoracic endovascular aortic repair (TEVAR) in a patient with ET entrapment in a new isolated dissecting aortic aneurysm.Case presentationA 50-year-old woman who underwent total arch replacement (TAR) with the ET technique 6 years ago was admitted with refractory hypertension and heart failure. Magnetic resonance angiography revealed that the ET was entrapped in an isolated dissecting aortic aneurysm, which obstructed blood flow, thus causing ischemia. She underwent TEVAR to reset the entrapment of the ET. After TEVAR, ischemic symptoms were immediately relieved.ConclusionWe present a case of new entry after the repair of a type A acute aortic dissection using ET, which rapidly progressed to a distal arch dissecting aneurysm and dislocation of the ET.

How to select the optimal size of frozen elephant trunk in total arch replacement for type A acute aortic dissection.

Total arch replacement (TAR) with a frozen elephant trunk (FET) is a common technique for acute aortic dissection, but there is no consensus on the optimal size of the FET. Forty-four patients who underwent TAR with FET for acute aortic dissection at our hospital since 2014 were included. The aortic diameter obtained from FET was measured on postoperative computed tomography (CT) and the estimated oversizing ratio was calculated. We investigated the relationship between the estimated oversizing ratio and postoperative outcomes. We also measured the maximum true lumen diameter, circumference of the true lumen, and total aortic diameter at the same level as the FET end on preoperative CT and examined the correlation with the aortic diameter obtained from FET. The average estimated oversizing ratio was 109%. Early postoperative CT showed complete thrombosis of the false lumen in 41 (93.2%) patients. No distal stent graft-induced new entry occurred during follow-up. The correlation coefficients between the three measurements and aortic diameter obtained from FET were 0.64 (maximum true lumen diameter), 0.76 (true lumen diameter calculated from circumference), and 0.72 (total aortic diameter), respectively. The aortic diameter obtained from FET on postoperative CT was strongly correlated with the true lumen diameter calculated from the circumference and total aortic diameter on preoperative CT. It is reasonable to select a size of approximately 130% of the true lumen diameter calculated from the circumference or 80% to 85% of the total aortic diameter.

Hybrid Technique on the Total Arch Replacement for Type A Aortic Dissection: 12-year Clinical and Radiographical Outcomes From a Single Center.

ObjectiveHybrid total arch replacement (HTAR) was an alternative for type A aortic dissection (TAAD). This study aimed to evaluate the clinical and radiographical outcomes of HTAR for TAAD and to evaluate the clinical outcomes of performing this procedure under mild hypothermia.MethodsA total of 209 patients who underwent HTAR for TAAD were retrospectively analyzed and stratified into mild (n = 48) and moderate (n = 161) hypothermia groups to evaluate the effects of mild hypothermia on the clinical outcomes. Long-term clinical outcomes were evaluated by the overall survival and adverse aortic events (AAEs). A total of 176 patients with preoperative and at least one-time postoperative aortic computed tomography angiography in our institute were included for evaluating the late aortic remodeling (aortic diameter and false lumen thrombosis).ResultsThe median follow-up period was 48.3 (interquartile range [IQR] = 28.4–73.7) months. The overall survival rate was 88.0, 83.2, and 77.1% at the 1, 5, and 10 years, respectively, and in the presence of death as a competing risk, the cumulative incidence of AAEs was 4.8, 9.9, and 12.1% at the 1, 5, and 10 years. The aortic diameters were stable in the descending thoracic and abdominal aorta (P > 0.05 in all the measured aortic segments). A total of 100% complete false lumen thrombosis rate in the stent covered and distal thoracic aorta were achieved at 1 year (64/64) and 4 years (18/18), respectively after HTAR. The overall composite adverse events morbidity and mortality were 18.7 and 10.0%. Mild hypothermia (31.2, IQR = 30.2–32.0) achieved similar composite adverse events morbidity (mild: 14.6 vs. moderate: 19.9%, P = 0.41) and early mortality (mild: 10.4 vs. moderate: 9.9%, P = 1.00) compared with moderate hypothermia (median 27.7, IQR = 27–28.1) group, but mild hypothermia group needed shorter cardiopulmonary bypass (mild: 111, IQR = 93–145 min vs. moderate: 136, IQR = 114–173 min, P < 0.001) and aortic cross-clamping (mild: 45, IQR = 37–56 min vs. moderate: 78, IQR = 54–107 min, P < 0.001) time.ConclusionHybrid total arch replacement achieved desirable early and long-term clinical outcomes for TAAD. Performing HTAR under mild hypothermia was as safe as under moderate hypothermia. After HTAR for TAAD, dissected aorta achieved desirable aortic remodeling, presenting as stable aortic diameters and false lumen complete thrombosis. In all, HTAR is a practical treatment for TAAD.

Comparison of Outcome of Total Arch Replacement for Type A Aortic Dissection using Trifurcated Branch Graft vs Island Technique- A Single Centre Experience

Comparison of Outcome of Total Arch Replacement for Type A Aortic Dissection using Trifurcated Branch Graft vs Island Technique- A Single Centre Experience

Four-branched graft inversion technique for the distal anastomosis in acute aortic dissection

BackgroundDistal anastomosis bleeding is an issue during total arch replacement with the frozen elephant trunk technique. We used the 4-branched graft inversion technique for the distal anastomosis in acute aortic dissection. The aim was to evaluate the feasibility and benefits of the technique used during the frozen elephant trunk procedure for acute aortic dissection.MethodsFrom January 2017 to July 2019, 109 patients underwent total arch replacement for type A acute aortic dissections. Patients were divided according to the technique used for the distal anastomosis as follows: group G (n = 57; 4-branched graft inversion technique) and group C (n = 52; conventional method with Teflon felt). The postoperative variables were analysed.ResultsThe hospital mortality rate was 9.2% (10/109). The mean cardiopulmonary bypass, cardiac arrest, and circulatory arrest times were 234.95 ± 71.88 min, 168.25 ± 61.33 min, and 39.19 ± 9.45 min, respectively. The circulatory arrest and cardiac arrest times were shorter in the graft inversion group than in the conventional group (36.46 ± 7.88 min vs. 42.19 ± 10.17 min, P = 0.001 and 156.21 ± 55.99 min vs. 181.44 ± 64.68 min, P = 0.031, respectively). There were 7 cases of stroke (6.4%) and 5 cases of paraplegia (4.6%). Additionally, 13 patients (11.9%) required temporary continuous renal replacement therapy. Respiratory failure occurred in 19 patients (17.4%). There were no significant differences in postoperative complications between the two groups.ConclusionsThe 4-branched graft inversion technique provides effective and confirmed haemostasis during total aortic arch replacement using the frozen elephant trunk procedure.

Optimal Degree of Hypothermia in Total Arch Replacement for Type A Aortic Dissection.

Background: We sought to investigate the best degree of hypothermic cardiac arrest (HCA) in type A aortic dissection (TAAD) with a cohort of 1,018 cases receiving total arch replacement from 2013 to 2018 in Fuwai Hospital.Method: The cohort was divided by DHCA (≤24°C, n = 580) vs. MHCA (>24°C, n = 438), and interquartile range (Q1–Q4). Primary endpoints included mortality, stroke, paraplegia, and continuous renal replacement therapy (CRRT), which were summarized as composite major outcomes (CMO).Results: The Odds Ratio (OR) of CMO for MHCA was 0.7 (95% CI: 0.5–1.0, p = 0.06) (unadjusted) and 0.6 (95% CI: 0.4–1.0, p = 0.055) (adjusted). DHCA group tended to have a significantly longer CPB time (175.6 ± 45.6 vs. 166.8 ± 49.8 min, p = 0.003), longer hospital stay (16.0 ± 13.6 vs. 13.5 ± 6.8 days, p < 0.001), and ICU stay [5.0 (3.9–6.6) vs. 3.8 (2.0–5.6) days]. A significantly greater blood loss was observed in DHCA group, with a greater requirement for RBC and platelet transfusion. Of note, MHCA showed a significant protective effect (60% risk reduction) for older patients (above 60 years) (OR 0.4; 95% CI: 0.2–0.8; p = 0.009). By quartering, Q1 had significantly higher mortality (10.9%) than Q4 (5.2%) (p = 0.035). For other comparisons, the gap was significantly widened in quartering between Q1 and Q4, i.e., the lower the temperature, the worse the outcomes, and vice versa. Propensity score matching and sensitivity analyses confirmed the above findings.Conclusions: A paradigm change from DHCA to MHCA may be encouraged in TAAD arch operation, especially for the elderly.

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．

Fate of distal aorta after frozen elephant trunk and total arch replacement for type A aortic dissection in Marfan syndrome

ObjectiveThe use of the frozen elephant trunk technique for type A aortic dissection in Marfan syndrome is limited by the lack of imaging evidence for long-term aortic remodeling. We seek to evaluate the changes of the distal aorta and late outcomes after frozen elephant trunk and total arch replacement for type A aortic dissection in patients with Marfan syndrome. MethodsBetween 2003 and 2015, we performed frozen elephant trunk + total arch replacement for 172 patients with Marfan syndrome suffering from type A aortic dissection (94 acute; 78 chronic). Mean age was 34.6 ± 9.3 years, and 121 were male (70.3%). Early mortality was 8.1% (14/172), and follow-up was complete in 98.7% (156/158) at a mean of 6.2 ± 3.3 years. Aortic dilatation was defined as a maximal diameter of greater than 50 mm or an average growth rate of greater than 5 mm/year at any segment detected by computed tomographic angiography. Temporal changes in the false and true lumens and maximal aortic size were analyzed with linear mixed modeling. ResultsAfter surgery, false lumen obliteration occurred in 86%, 39%, 26%, and 21% at the frozen elephant trunk, unstented descending aorta, diaphragm, and renal artery, respectively. The true lumen expanded significantly over time at all segments (P < .001), whereas the false lumen shrank at the frozen elephant trunk (P < .001) and was stable at distal levels (P > .05). Maximal aortic size was stable at the frozen elephant trunk and renal artery (P > .05), but grew at the descending aorta (P = .001) and diaphragm (P < .001). Respective maximal aortic sizes before discharge were 40.2 mm, 32.1 mm, 31.6 mm, and 26.9 mm, and growth rate was 0.4 mm/year, 2.8 mm/year, 3.6 mm/year, and 2.6 mm/year. By the latest follow-up, distal maximal aortic size was stable in 63.5% (99/156), and complete remodeling down to the mid-descending aorta occurred in 28.8% (45/156). There were 22 late deaths and 23 distal reoperations. Eight-year incidence of death was 15%, reoperation rate was 20%, and event-free survival was 65%. Preoperative distal maximal aortic size (mm) predicted dilatation (hazard ratio, 1.11; P < .001) and reoperation (hazard ratio, 1.07; P < .001). A patent false lumen in the descending aorta predicted dilatation (hazard ratio, 3.88; P < .001), reoperation (hazard ratio, 3.36; P = .014), and late death (hazard ratio, 3.31; P = .045). ConclusionsThe frozen elephant trunk technique can expand the true lumen across the aorta, decrease or stabilize the false lumen, and stabilize the distal aorta in patients with Marfan syndrome with type A aortic dissection, thereby inducing favorable remodeling in the distal aorta. This study adds long-term clinical and radiologic evidence supporting the use of the frozen elephant trunk technique for type A dissection in Marfan syndrome.

Silent coronary rupture treated with coronary emboliza-tion two years after total arch replacement

We experienced a case of asymptomatic coronary artery rupture two years after type A acute aortic dissection which was successfully treated with coronary embolization. A 51-year-old man underwent total arch replacement for type A acute aortic dissection two years ago. Although he had been followed uneventfully, follow-up computed tomography scan two years after the operation incidentally identified the hemopericardium compressing the posterolateral wall of the left ventricle. Echocardiography showed significant compression of the left ventricle due to the hemopericardium, but did not show any deterioration of cardiac function. ECG-gated 320-sliced multi-detector computed tomography (MDCT) revealed extravasation from the left circumflex artery. He was hemodynamically stable and asymptomatic despite this potentially life threating condition. After the admission, coronary angiography was performed which revealed coronary artery rupture from the distal part of the second obtuse marginal artery (OM2). The artery was successfully treated with coil embolization. However, four-dimensional computed tomography (4D-CT) three days after the embolization still showed persistent extravasation from the first obtuse marginal artery (OM1). As the artery dominated large areas, OM1 was treated with absorbable gelatin sponge particles. 6 months after the procedures, additional coil embolization was performed for recurrence bleeding from these arteries. After these coil embolization, cardiac enzymes were slightly elevated, but no deterioration of cardiac function was noted and successful hemostasis were achieved. Although considerably rare, asymptomatic coronary artery rupture could happen after the thoracic surgery. 4D-CT is efficient for identifying ruptured sites and coronary embolization is reasonable treatment to achieve hemostasis.

Bilateral versus unilateral antegrade cerebral perfusion in total arch replacement for type A aortic dissection

BackgroundAntegrade cerebral perfusion (ACP) is the most widely used cerebral protection strategy for complex aortic repair and includes unilateral (u-ACP) and bilateral (b-ACP) techniques. The superiority of b-ACP over u-ACP has been the subject of much debate. Focusing on type A aortic dissection requiring total arch replacement, we investigated the clinical effects of b-ACP versus u-ACP. MethodsBetween September 2006 and August 2014, 203 patients presenting with type A aortic dissection (median age, 51.0 ± 13 years; range, 17-72 years; 128 males) underwent total aortic arch replacement with hypothermic circulatory arrest. ACP was used in all patients, including u-ACP in 82 (40.3%) and b-ACP in 121 (59.7%). ResultsThere was no significant difference between the u-ACP and b-ACP groups in terms of cardiopulmonary bypass (CPB) time, cross-clamp time, or circulatory arrest time. Overall 30-day mortality was comparable in the 2 groups (11.6% for b-ACP vs 20.7% for u-ACP; P = .075). The prevalence of postoperative permanent neurologic dysfunction (PND) was comparable as well (8.4% vs 16.9%; P = .091). Mean ventilation time was lower in the b-ACP group (95.5 ± 45.25 hours vs 147.0 ± 82 hours; P < .001). Mean lengths of stay in the intensive care unit and the hospital overall were comparable in the 2 groups (intensive care unit: 16 ± 17.75 days vs 17 ± 11.5 days, P = .454; hospital: 26.5 ± 20.6 days vs 24.8 ± 10.3 days, P = .434). The P values from logistic regression models indicated that in the 2 groups combined, CPB time and circulatory arrest time were independent risk factors for both mortality and PND. ConclusionsIn this, the first published study focusing on the efficacy of u-ACP and b-ACP in total arch replacement for type A aortic dissection, the b-ACP group did not demonstrate significantly lower 30-day mortality or PND rate compared with the u-ACP group. Future large-sample studies are warranted to thoroughly examine this critical issue.

Left Ventricular Pseudo-Aneurism after Transapical Aortic Cannulation in Ehlers-Danlos Syndrome Type IV: A Case Report

Introduction: We report a case of Ehlers-Donlos syndrome which raised left ventricular pseudo-aneurism at the site of transapical aortic cannulation after acute aortic dissection repair. Case Report: A 49-year-old male underwent total arch replacement for type A aortic dissection using transapical aortic cannulation. CT revealed a pseudoaneurysm at the left ventricular apex 2 weeks after the initial surgery, and the size of pseudoaneurysm increased in another 2 weeks. We performed reoperation and found suture dehiscence of transapical cannulation closure. Post-operative course was uneventful. He was diagnosed as Ehlers-Donlos syndrome by genetic examination after the second surgery. Conclusion: Ehlers-Danlos syndrome might be attributed to vulnerability of cardiac muscle and suture dehiscence, and transapical cannulation should be carefully applied in the patients with Ehlers-Danlos syndrome.

EComment. Hemiarch or total arch replacement for type A aortic dissection?

eComment. Hemiarch or total arch replacement for type A aortic dissection?

Frozen elephant trunk with total arch replacement for type A aortic dissections: Does acuity affect operative mortality?

We seek to compare the early outcomes of frozen elephant trunk with total aortic arch replacement using a 4-branched graft (the Sun procedure) in patients with acute and chronic type A aortic dissection (TAAD), identify the risk factors for operative mortality, and determine whether the acuity of TAAD significantly affects operative mortality. We performed univariate and multivariate analyses of the clinical data from 803 patients with TAAD who underwent the Sun procedure. The operative mortality was 6.5% (52 of 803). The overall incidence of stroke and spinal cord injury was 2.0% (16 of 803) and 2.4% (19 of 803), respectively. Patients with acute TAAD had a greater incidence of operative death (8.1% vs 4.3%; P = .031), stroke (2.2% vs 0.6%; P = .046), and respiratory morbidities (20.8% vs 8.6%; P < .001). However, acuity was not identified as a risk factor for operative mortality (odds ratio [OR], 1.67; P = .152). The risk factors were previous cerebrovascular disease (OR, 7.01; P = .001); malperfusion of the brain (OR, 7.10; P = .002), kidneys (OR, 12.67; P = .005), spinal cord (OR, 22.79; P = .008), and viscera (OR 22.98; P = .002); concomitant extra-anatomic bypass (OR, 9.50; P < .001); and cardiopulmonary bypass time >180 minutes (OR, 1.01; P < .001). In this group of patients with type A dissection, acuity was not a risk factor for operative mortality after the Sun procedure. Patients with previous cerebrovascular disease; malperfusion of the brain, kidneys, spinal cord, and/or viscera; concomitant extra-anatomic bypass; and a longer cardiopulmonary bypass time (>180 minutes) were at greater risk of operative mortality.

Treatment strategies for left subclavian artery during total arch replacement combined with stented elephant trunk implantation

One of the technical challenges in total arch replacement for type A aortic dissection is the left subclavian anastomosis and the descending aortic anastomosis. We present a technique that simplifies this surgery. A total of 33 consecutive patients (mean age, 48.0 ± 11.6 years) with acute Stanford type A aortic dissection who underwent a total arch replacement were included in this study. Instead of anastomosing the graft to the descending aorta distal to the left subclavian artery, we ligated the left subclavian artery and performed the distal aortic anastomosis between the left carotid artery and the left subclavian artery. The left subclavian artery is then revascularized with a side arm from our aortic graft through the first intercostal space to the left axillary artery. The descending aorta also is stented in an antegrade fashion under direct visualization. Both intraoperative and postoperative complications were then noted. All enrolled patients underwent total arch replacement performed using this newly introduced technique with a mortality rate of 18.2% (6/33). The causes of mortality were multiorgan failure (4 patients), renal failure (1 patient), and postoperative sepsis (1 patient). There was no intraoperative death and no anastomotic leak in our study cohort. Limb ischemia was observed in 4 patients, with all occurring in the lower limb. Postoperative delirium also was observed in 5 patients. The left subclavian artery bypass technique during total arch replacement for type A dissection is reliable and simplifies the surgery by bringing the descending aortic anastomosis more proximal and eliminating the difficult left subclavian artery anastomosis.

Long-Term Effectiveness of Total Arch Replacement for Type A Aortic Dissection

With recent improvements in cerebral protection during aortic arch repair, total aortic arch replacement has become an accepted surgical method for acute type A aortic dissection involving the aortic arch. Our surgical strategy is to perform total arch replacement with a branched graft using antegrade selective cerebral perfusion for the patients with type A aortic dissection involving the aortic arch. The objective of this study is to evaluate the effectiveness of this strategy on late outcome. From October 1988 to April 2003, 46 patients underwent total arch replacement for acute type A dissection involving the aortic arch. Operations were performed with hypothermic cardiopulmonary bypass, antegrade selective cerebral perfusion during the arch repair, and open distal anastomosis. Hospital mortality was 6.5% (3 patients), and permanent neurologic dysfunction was observed in 1 patient. During the follow-up period (mean, 5.4 years; range, 13 months to 15.6 years), 2 patients died, but the causes were not related to the aorta or aortic valve. Survival rates at 5 and 10 years postoperatively were 89.6% +/- 5.2% and 82.7% +/- 8.2%, respectively. Of the 41 survivors, 3 patients underwent successful reoperation for the distal thoracic aorta. Freedom from reoperation was 93.6% +/- 4.6% and 88.7% +/- 6.5% at 5 and 10 years, respectively. The residual false lumen in the thoracic aorta was frequently thrombosed (76.2%). Total arch replacement for acute type A dissection may decrease the risk of late complications related to the false lumen and lead to excellent long-term survival.

Invited commentary

Despite advances in operative techniques and postoperative care, repair of aortic dissection involving the arch remains a challenging and high-risk procedure. Moreover, extended aortic arch replacement still carries a considerable operative risk. However, this is a timely subject, as it addresses integral treatment of a lethal condition.In this issue, Ochiai and colleagues [1Ochiai Y. Imoto Y. Sakamoto M. et al.Long-term effectiveness of total arch replacement for type A aortic dissection.Ann Thorac Surg. 2005; 80: 1297-1302Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar] report results of an operative strategy of total aortic arch replacement using a branched graft in cases of type A aortic dissection with arch involvement. This is a large experience and presents one of the largest casuistic so far on this subject, comparing favorably with previous studies. The rationale is the operative treatment of wider segments of the diseased aorta and more complete resection of intimal tears, which reduces the long-term complication rate.The value of the study is the extended follow-up; for this reason this report is quite interesting. Few studies report long-term follow-up of patients who had total aortic arch replacement. Importantly, the procedure was accomplished with low mortality; the distal false lumen in the aorta was thrombosed in more than 70% of patients at latest follow-up; and no patient required aortic arch reoperation. Freedom from reoperation was 98.0% at 5 years and 94.4% at 10 years. Frequent complications usually related to acute type A aortic dissections and a poorer postoperative prognosis (eg, renal and mesenteric ischemia, paraplegia, limb ischemia, Marfan syndrome) were not found in the present study. Surely, absence of these complications contributed to the excellent outcome and may justify greater perioperative morbidity and mortality in higher risk patients.This article endorses the fact that contemporary cerebral protection methods, proper indications, and total arch replacement can produce acceptable mortality in patients with type A aortic dissection and provide more satisfactory long-term outcomes. The information provided by this study supports and encourages aggressive treatment of this disease. Despite advances in operative techniques and postoperative care, repair of aortic dissection involving the arch remains a challenging and high-risk procedure. Moreover, extended aortic arch replacement still carries a considerable operative risk. However, this is a timely subject, as it addresses integral treatment of a lethal condition. In this issue, Ochiai and colleagues [1Ochiai Y. Imoto Y. Sakamoto M. et al.Long-term effectiveness of total arch replacement for type A aortic dissection.Ann Thorac Surg. 2005; 80: 1297-1302Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar] report results of an operative strategy of total aortic arch replacement using a branched graft in cases of type A aortic dissection with arch involvement. This is a large experience and presents one of the largest casuistic so far on this subject, comparing favorably with previous studies. The rationale is the operative treatment of wider segments of the diseased aorta and more complete resection of intimal tears, which reduces the long-term complication rate. The value of the study is the extended follow-up; for this reason this report is quite interesting. Few studies report long-term follow-up of patients who had total aortic arch replacement. Importantly, the procedure was accomplished with low mortality; the distal false lumen in the aorta was thrombosed in more than 70% of patients at latest follow-up; and no patient required aortic arch reoperation. Freedom from reoperation was 98.0% at 5 years and 94.4% at 10 years. Frequent complications usually related to acute type A aortic dissections and a poorer postoperative prognosis (eg, renal and mesenteric ischemia, paraplegia, limb ischemia, Marfan syndrome) were not found in the present study. Surely, absence of these complications contributed to the excellent outcome and may justify greater perioperative morbidity and mortality in higher risk patients. This article endorses the fact that contemporary cerebral protection methods, proper indications, and total arch replacement can produce acceptable mortality in patients with type A aortic dissection and provide more satisfactory long-term outcomes. The information provided by this study supports and encourages aggressive treatment of this disease.