Acute type I aortic dissection: ‘is simultaneous descending stent grafting justified?’

The question of how far the dissected arch should be replaced in an acute Type A aortic dissection is not new. With the development of the frozen elephant trunk (FET) [1, 2] and the development of the first commercially available prosthesis [3], the era of the FET began. With the first multicentre studies on the application of the FET in acute aortic dissections, the authors already asked the right question in 2010 with the title of their work ‘Multicentre early experience with extended aortic repair in acute aortic dissection: is simultaneous descending stent grafting justified?’ [4]. Roselli et al. have made another contribution to answering this question with their remarkable work based on 40 years of experience with 879 well-documented acute DeBakey type I dissections [5]. In their article ‘The modified Frozen Elephant Trunk May Outperform Limited and Classic Extended Repair in Acute Type I Dissection’, Roselli et al. compare the outcomes of patients treated over the years with 3 different methods. Most (80%) of the patients were treated with a limited proximal aortic replacement with an open distal anastomosis and hemiarch replacement. The remaining 10% each underwent a classic complete arch replacement or an arch replacement with combined antegrade stent grafting in the form of a modified frozen elephant trunk (mFET) operation. In the presented cohort, the proportion of patients treated with mFET continuously increased, replacing the classic arch replacement and accounting for about 50% of the treated type I dissections in 2018. By propensity score matching, 3 comparable groups could be identified, allowing for the comparison of limited versus extended classic repair, extended-classic versus mFET, and the comparison of the results of the mFET with those of the limited proximal repair.