Commentary: Technology and Technique

摘要

In acute type A aortic dissection (aTAAD), total arch replacement (TAR) with frozen elephant trunk (FET) is controversial outside of the indications of tear involvement or significant aneurysm of the arch. While some single-center studies have suggested that TAR imposes no additional mortality to aTAAD repair,data from clinical registries, meta-analyses, and the Society of Thoracic Surgeons (STS) database have shown significantly higher mortality rates with TAR than with hemiarch repair. Furthermore, meta-analyses suggest that the benefit of freedom from long-term aortic reoperation is not necessarily realized by TAR. In this edition of Operative Techniques, Shrestha et al present their technique for this complex operation. It should be noted that this is an "arch-last" technique, with a Zone 2 anastomosis and branch grafts to all of the supra-aortic vessels, utilizing the only hybrid branched graft that is available in Europe and the United States (Terumo Aortic, Renfrewshire UK and Sunrise FL). While the hybrid nature of the graft does simplify the procedure, there are number of technique choices that are notable for their potential impact on operative outcomes. These are worth a brief discussion. First, the cannulation technique is described as primarily aortic either by echo-guided Seldinger technique or by direct open cannulation. Establishing central, antegrade flow may be beneficial in mitigating malperfusion and reducing atherosclerotic embolization, as well as facilitating a shorter time to establishing cardiopulmonary bypass. Second is the authors' cerebral perfusion strategy. The superiority of retrograde cerebral perfusion (RCP) vs antegrade cerebral perfusion (ACP) remains an area without clear consensus. As the authors propose, a strategy using initial RCP for embolic washout followed by ACP provides an "and" rather than "either/or" approach that may garner benefits of both techniques. Last, the authors take advantage of an upfront completed proximal graft to establish continuous myocardial perfusion during the arch operation, reducing myocardial ischemic time.