New concepts in Aortic Arch Repair. Are we Heading in the Right Way?

The standard approach for repair of type A aortic dissection includes repair or replacement of the aortic valve, the ascending aorta and the arch, alone or in combination with direct vision under hypothermic circulatory arrest. Although type A dissection usually extends into the distal thoracoabdominal aorta, the descending thoracic aorta is usually left alone. During the follow-up, surgeons will sequentially and periodically evaluate the patients looking for aneurysmal dilatation of the untreated aorta for an eventual late open surgical or endovascular repair. Surgery of the aorta continues to be a surgical challenge. Aortic disease and surgery are dynamic as new ideas are continuously brought up in terms of surgical approach, extension of repair and characterization of patients. Technology also plays an important role nowadays. Since the early days of high-porosity vascular grafts, until today where vascular grafts are being coated with albumin or collagen, results have dramatically changed in terms of control of hemorrhage and related intraoperative death. The inception of endovascular therapy seems to change the perception of patients suffering from descending thoracic aortic aneurysms and chronic dissections.1 Acute type B dissections are still a matter of concern regardless of the attempted therapy. Type A dissection routinely involves the aortic arch. Operation-related morbidity and mortality is still high. Some questions are still unanswered; like the need of performing complex combined resections of the arch and how to treat the descending aorta. To save the patient first has always been our major surgical standard and we believe this must always be priority in the critical decision-making process. Here we will have a quick look at evolving concepts, ideas and technologies, asking some questions for the near future.