We should replace the aortic arch and more in DeBakey type I dissection - A perspective from the Cleveland Clinic.

A frequently debated question in aortic arch surgery has been: should we replace the dissected arch in type A dissection? As techniques improve the answer is shifting towards ‘yes’ more often than ‘no’. Arguments in favor of a more extensive repair for DeBakey type 1 dissection, however, are not new. In the early 1980s operative techniques for this disease were refined to greatly reduce operative deaths, especially those attributable to bleeding complications (1, Lytle BW: personal communication) (See Figure 1). These advances occurred at a time when the use of circulatory arrest was becoming more widely disseminated and the elephant trunk repair was being introduced (2,3). Not long after that, several pioneering aortic surgeons demonstrated in the mid-1990s that more extensive arch repairs were not only safe, but effective at promoting distal aortic remodeling in patients presenting with acute type 1 dissection (4-7). Nonetheless, over the last two and a half decades, the most common operation performed in this emergency setting is a supra-coronary ascending and hemi-arch interposition graft repair. The reluctance to perform more extensive repairs at the time of acute proximal aortic dissection is due to concerns that performing a bigger operation will increase the perioperative mortality (8-10). Figure 1 The curve represents the decreasing trend in operative mortality year by year (represented by black dots) at the Cleveland Clinic from 1980 to 2004. Note a major shift in the curve in the mid-1980s Within the last decade, endovascular stent-graft devices have been widely adopted to treat thoracic aortic disease. Novel hybrid strategies combining the use of these devices with conventional open surgery show promise to simplify more extensive aortic repair at the time of acute dissection (11-19). With wider access to endovascular devices, brain protection strategies becoming more commonplace, and reproducible results with hybrid repairs, is only repairing the ascending aorta good enough in the modern era? I believe that the answer to this question is a resounding ‘no’. We should replace the arch and more in patients who present with acute DeBakey type 1 aortic dissection. I believe that embracing these newer techniques will allow us to make the incremental improvements in outcomes for acute proximal dissection that have not been seen since the mid-1980s.