Strategies in the surgical treatment of type A aortic arch dissection.

Aortic dissection involving the ascending aorta is a lethal condition, with mortality approaching 60% if surgical intervention is not performed early (1). Stanford type A acute aortic dissection involves the ascending aorta, aortic arch and a variable extent of the descending thoracic aorta. Identification and resection of the primary intimal tear with re-approximation of the intima and adventitia remains the surgical principle of repair. Despite using this approach, a residual dissection flap persists in the arch and descending thoracic aorta in 64-90% of patients (2-5). This can lead to distal malperfusion in the acute setting (6), with a risk of aneurysm formation and rupture over the long term (7). Despite the advancement of cardiac surgery techniques, employment of modern cerebral protection strategies, myocardial protection, and aortic graft development, the surgical mortality of these operations, even in centers with a specific interest in aortic surgery, is in the range of 25% (8). In the modern era of cardiac surgery, it is rare to undertake a “common” operation with a mortality of 25% and this serves as a challenge for the cardiac surgery community to improve. In order to reduce this high operative mortality, one first needs to understand the contributing factors.