The treatment of aortic arch pathologies is becoming progressively more complex and multidisciplinary. Despite progresses in open surgical techniques, the high rate of surgical morbidity and mortality, especially in frail and elderly patients, has led to the development of alternative treatment options to conventional open surgery such as hybrid and endovascular procedures. Our purpose is to summarize the advantages and disadvantages of the different approaches and investigate the role of a dedicated aortic team in the choice of the most appropriate treatment for each patient.

Addressing proximal complications that arise after endovascular aortic repair for type B aortic dissection, such as type Ia endoleaks, \"bird-beaking\" of the thoracic endovascular aortic repair (TEVAR) stent, retrograde type A dissection, and postdissection aneurysms, bears considerable complexities. We present a novel and safe method for open arch repair that can ensure a secure and efficient approach for TEVAR complications. The key element of the operative technique is approximating the grafted stent portion to the aortic wall and the arch prosthesis. The technique has successfully been implemented in 11 patients, who received secondary open arch repair from 2019 to 2022 after TEVAR for type B dissection. Our objective is not only to introduce this reliable concept but also to provide a comprehensive demonstration of its advantages and disadvantages compared with currently used open treatment methods and discuss patient outcomes after secondary open arch repair.

BACKGROUND: This study aimed to elucidate the methodology and assess the efficacy of the aortic arch inclusion technique using an artificial blood vessel in managing acute type A aortic dissection (ATAAD).
METHODS: We conducted a retrospective review of 18 patients (11 males and 7 females, average age: 56.2 ± 8.6 years) diagnosed with ATAAD who underwent total aortic arch replacement (TAAR) using an artificial vascular \"inclusion\" between June 2020 and October 2022. During the operation, deep hypothermic circulatory arrest (DHCA) and selective antegrade cerebral perfusion (ACP) of the right axillary artery were employed for brain protection. The \'inclusion\' total aortic arch replacement and stented elephant trunk (SET) surgery were performed.
RESULTS: Four patients underwent the Bentall procedure during the study, with one additional patient requiring coronary artery bypass grafting (CABG) due to significant involvement of the right coronary orifice. Three patients died during postoperative hospitalization. Other notable complications included two cases of postoperative renal failure necessitating continuous renal replacement therapy (CRRT), one case of postoperative double lower limb paraplegia, and one case of cerebral infarction resulting in unilateral impairment of the left upper limb. Eleven patients underwent computed tomography angiography (CTA) examinations of the aorta three months to one-year post-operation. The CTA results revealed thrombosis in the false lumen surrounding the aortic arch stent in seven patients and complete thrombosis of the false lumen around the descending aortic stent in eight patients. One patient had partial thrombosis of the false lumen around the descending aortic stent, and another patient\'s false lumen in the thoracic and abdominal aorta completely resolved after one year of follow-up.
CONCLUSIONS: Incorporating vascular graft in aortic arch replacement simplifies the procedure and yields promising short-term outcomes. It achieves the aim of total arch replacement using a four-branch prosthetic graft. However, extensive sampling and thorough, prolonged follow-up observations are essential to fully evaluate the long-term results.

Intraluminal thrombus formation (ILT) is a recently discovered and highly clinically relevant complication after frozen elephant trunk implantation in cardiovascular surgery. In this phenomenon, a thrombus forms within the lumen of the stent graft component of the frozen elephant trunk prosthesis and puts the patient at risk for downstream embolization with visceral or lower limb ischemia. Incidence of ILT reported in the currently available studies ranges from 6% to 17% of patients after frozen elephant trunk implantation. Adverse thromboembolic events include acute occlusion of the celiac and superior mesenteric arteries, both renal arteries as well as acute lower limb ischemia due to iliac or femoral artery embolization that not infrequently require interventional or open embolectomy. Therefore, the presence of ILT is associated with increased short-term mortality and morbidity. Currently proposed strategies to avoid ILT formation include a more aggressive anticoagulation management, minimization of postoperative coagulation factor application, and even technical optimizations of the stent graft portion itself. If ILT is manifested, the therapeutic strategies tested to date are long-term escalation of anticoagulation and early endovascular extension of the FET stent graft with overstenting of the intraluminal thrombus. The long-term efficiency of these prophylactic and therapeutic measures has yet to be proven. Nonetheless, all surgeons performing the frozen elephant trunk procedure must be aware of the risk of ILT formation to facilitate a timely diagnosis and therapy.

(1) Background: Conventional open surgery is still the gold standard for aortic arch disease, and despite recent developments in optimizing strategies for neuroprotection, distal organ perfusion, and myocardial protection, aortic arch replacement is still associated with high morbidity and mortality rates. (2) Methods: We present our case series of 12 patients undergoing surgical management of multiple cardiac diseases involving the aortic arch. In this single-center study, we report our initial experience over a five-year period (from December 2018 to October 2023) with the use of a \"debranching first\" technique for the supra-aortic vessels of a beating heart, followed by the cardiac step addressing proximal diseases, and a final distal step treating the aortic arch. This strategy aims to minimize cardiac, cerebral, and peripheral ischemia. (3) Results: Six patients underwent aortic root replacement with either Bentall (n = 4) or valve-sparing aortic root (David procedure) (n = 2). The mean nasopharyngeal temperature was 34 °C and the mean cardiocirculatory arrest was 14.3 min. The early mortality was 8.3% (1 patient); no patient experienced a permanent neurologic event. (4) Conclusions: In patients with complex aortic disease and concomitant cardiac disease, this approach reduces the need for hypothermia and decreases cardiopulmonary bypass time and myocardial arrest time and therefore could represent a valid surgical option, even in high-risk patients.

With advancement of hybrid and endovascular techniques, there are very few indications for open arch replacement. Major advancements in open arch replacement include antegrade perfusion-based cerebral protection, and an endovascular compliant arch replacement. In the present article, we demonstrate and describe our technique of Bentall\'s procedure and endovascular compliant arch replacement in a young Marfan\'s patient with chronic type A dissection and root aneurysm.
UNASSIGNED: The online version contains supplementary material available at 10.1007/s12055-023-01560-1.

BACKGROUND: The classical elephant trunk (ET) technique is a very useful surgical procedure; however, haemolysis in the aorta associated with ET has been previously reported. It normally occurs within several years after the surgery, and it is a rare case of rapidly progressing haemolysis 10 or more years after aortic arch replacement with ET.
METHODS: A 53-year-old man with a history of Stanford type A aortic dissection (DeBakey type Is), who was treated with total arch aortic replacement and aorto-femoral bypass using a prosthetic graft 17 years ago, developed severe progressive haemolytic anaemia. The ET used for the initial surgery was narrowed, and mechanical haemolysis was suspected. We assumed that progressive mechanical haemolysis occurred because of degeneration of the prosthetic graft. Thoracic endovascular aortic repair was performed, and haemolysis and anaemia were mitigated postoperatively.
CONCLUSIONS: Haemolysis occurred 17 years after the initial surgery with ET. When haemolysis is suspected in a patient with ET, it must be identified as a cause of haemolysis even if 10 years or more have passed since the ET was inserted. To prevent this complication, attention should be paid to an appropriate ET length and diameter to avoid folding of the ET, particularly when the true cavity diameter is small.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: \'Can a \"branch-first\" approach to aortic arch replacement be safely utilized in Stanford type A acute aortic syndromes?\' Altogether 64 papers were found using the reported searches, of which 10represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All papers included in this BET reported acceptable mortality and/or neurological outcomes in comparison to currently published standards for traditional repair. We conclude that while there is a need for larger series, direct comparison and long-term follow-up, the \'branch-first\' approach to aortic arch replacement has been safely performed in several centres in the setting of acute aortic syndromes with results demonstrating acceptable mortality, neurological outcomes and mid-term survival.

UNASSIGNED: The 2 most acceptable techniques for reimplantation of the supra-aortic vessels in total arch replacement include the branched graft technique (debranching) or en bloc technique (island). We aim to review our experience with total arch replacement and report short- and long-term outcomes from a high-volume center dedicated to surgery for the thoracic aorta.
UNASSIGNED: The aortic surgery database was queried to identify all consecutive patients undergoing total arch replacement between 1997 and 2022. Of the 426 patients who underwent total arch replacement, 303 (71%) received the island technique and 123 (29%) received the debranching approach. Operative and long-term outcomes were compared using multivariable models.
UNASSIGNED: The debranching group was younger (64 ± 14 years vs 69 ± 12 years, P = .001), had undergone more previous cardiac operations (54.5% vs 27.4%, P < .001), and had more connective tissue disorder (20.3% vs 4.6%, P < .001). The debranching approach was associated with longer total circulatory arrest time (47 ± 15 minutes vs 37 ± 10 minutes, P < .001) and cardiac ischemic time (116 ± 41 minutes vs 100 ± 37 minutes, P < .001). More patients in the debranching group received blood products intraoperatively or postoperatively (56.1% vs 42.9%, P = .018). All other early outcomes did not differ between groups. Overall operative mortality was 1.4% (2.4% vs 1%, P = .486); the incidence of major postoperative complications was 6.3% (5.7% vs 6.6%, P = .897). Ten-year survival was 80% (78% vs 80.9%, log-rank P = .356). Multivariable Cox regression analysis demonstrated that neither surgical approach was associated with survival advantage (hazard ratio, 1.18; 0.73-1.89; P = .495).
UNASSIGNED: Debranching requires a longer operative time, with similar early and long-term outcomes. Preoperative comorbidity, not surgical technique, predicts major adverse events and long-term survival.

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