Frozen elephant trunk and hemiarch for type A aortic dissection

Type A aortic dissection (TAAD) is a surgical emergency, which has the potential to cause malperfusion in multiple organ systems. Perioperative morbidity and mortality, even in the most experienced centers, continues to be in double-digit. The natural history of patients who survive initial surgery is marred by distal aortic degeneration, which is responsible for decreased survival during midterm follow-up, significant late reintervention rate with associated morbidity and mortality, and also need for tighter surveillance during the follow-up. Aggressive hemiarch replacement with direct intimal repair and antegrade stent graft in the descending thoracic aorta (DTA) not only stabilizes the ascending aorta and aortic arch in the acute setting, it also retards continuous degeneration of the downstream aorta. In the immediate postoperative period, a stent graft in the DTA placed in an antegrade manner, eliminates the possibility of type 1a endoleak. Coverage of distal fenestration in DTA and true lumen stabilization with a rigid graft has the potential to mitigate malperfusion in this delicate patient population. In the long run, a stent graft in the DTA promotes aortic remodeling, provides a stable framework for future open/endovascular re-intervention. In this review article, we have detailed our operative approach in patients with TAAD, and discussed variables relevant for a good outcome.