Hemiarch replacement with aortic root preservation for acute type A aortic dissection

Abstract

Acute Type A aortic dissection (TAAD) is a surgical emergency requiring expeditious management. The surgical principles involve restoration of true lumen blood flow with obliteration of the primary tear thereby mitigating malperfusion and restoring valvular competency. At our institution 60% of TAAD patients are treated with a hemiarch and the other 40% are treated with a total arch replacement (TAR). All cases employ the use of cerebral protection. For hemiarch replacement, retrograde cerebral perfusion (RCP), via the superior vena cava (SVC), is utilized. Antegrade cerebral perfusion is utilized via brachiocephalic vessels during a TAR. Electroencephalogram (EEG) and somatosensory evoked potentials (SSEP) are used for neurocerebral monitoring with the aim of electrical silence before circulatory arrest. Key radiographic and clinical findings are used to adjudicate between these two procedures pre and intraoperatively. Patients with any of the following undergo a TAR at our institution: (I) aortic arch aneurysm, (II) primary or re-entry tear in the aortic arch or proximal descending aorta, (III) circumferential dissection of the aortic arch, or (IV) carotid body dissection or thrombosis. Irrespective of the procedure chosen, central aortic cannulation is routinely performed via modified Seldinger technique with transesophageal echocardiography guidance. The proximal aorta is addressed while the patient is systemically cooled to hypothermia. All effort is made to retain the native aortic root and valve where possible. However, in cases where the aortic root is dilated or has a tear, a valve sparing root replacement or a modified Bentall is performed. The operative strategy for a TAAD at our institution is predicated on a tear-based paradigm.However, the extent of aortic reconstruction may be different based on surgeon and center experience.

Sex‐based outcomes after surgery for acute type A aortic dissection

“…Finally, a frozen elephant trunk was performed in any cases of distal arch tear at or beyond the origin of the left subclavian, severe pseudocoarctation, and/or significant dilation of the proximal descending aorta with concern for disruption. [10][11][12]…”

Sex-based Outcomes after Surgery for Acute Type A Aortic Dissection

“…Total arch replacement with antegrade cerebral perfusion (ACP) was performed if any of the following pathologies were present: 1) primary or secondary arch tear, 2) circumferential arch dissection, 3) arch aneurysm, or 4) carotid dissection resulting in cerebral malperfusion. Finally, a frozen elephant trunk was performed in any cases of distal arch tear at or beyond the origin of the left subclavian, severe pseudocoarctation, and/or significant dilation of the proximal descending aorta with concern for disruption [10,11,12].…”