Extensive Repair in Type A Aortic Dissection: To Save the Patient or to Ensure a Durable Repair?

Type A aortic dissection (TAAD) is a serious condition requiring emergency surgical management. The main objective of the treatment is the patient survival. Thus, the surgeon has to perform a well-mastered surgical technique without extending the operative time and emphasizing operative risk. Nevertheless, patients with history of TAAD present long-term complications on the aorta, mainly aneurysmal evolution and dissection recurrence. In order to decrease the long-term excess mortality of this population, it is necessary to respect some rules during the surgery. Concerning the proximal segment of the ascending aorta, the aortic root has to be replaced by a composite graft (Bentall technique) or a valve sparing inclusion (David technique) when the dissection reaches the sinuses of Valsalva or when aortic valve regurgitation is observed. Concerning the distal segment of the ascending aorta, the distal anastomosis has to be performed without aortic clamping. Concerning the descending thoracic aorta, hybrid surgery should be performed on patients with malperfusion syndrome and patients with high risk factors for aneurysmal evolution