Trends and controversies in type A aortic surgery in the 21st century: Branch first aortic arch replacement

BACKGROUND: Acute type A dissection (ATAAD) remains a morbid condition with reported surgical mortality as high as 26%. AIMS: We describe our surgical approach to ATAAD using a "branch first" total arch replacement technique which avoids a traditional approach of ascending aorta and "hemi-arch" replacement utilising deep hypothermic circulatory arrest (DHCA) and an open distal anastomosis. We also discuss the indications for adjunct techniques such as the frozen elephant trunk or complete aortic repair with endovascular methods. MATERIALS & METHODS: Thirty-nine patients underwent a "branch first" total aortic arch replacement for ATAAD. RESULTS: We had an overall 5(12.8%) hospital mortalities and 2 (5.1%) strokes. There were no deaths or strokes in patients without pre-operative organ malperfusion or shock. DISCUSSION: Arch replacement using the "branch-first technique" allows for complete proximal aortic replacement and sets up for straightforward future distal aortic intervention. CONCLUSION: The use of a branch first aortic arch replacement technique in ATAAD results in improved outcomes and is an approach applicable to all cardiac surgeons not only the aortic sub specialist