Significant controversy exists in the management of type A aortic
dissections with aortic arch involvement. There is a substantial
variability in approaches to this complex problem ranging from simply
replacing the ascending aorta to total arch replacement with frozen
elephant trunk -- all of which balance the competing interests of
reducing operative risk and reducing risk of reintervention. The
diversity of clinical details, variability of surgical experience, and
lack of significant randomized data make a consensus approach to these
patients unlikely. However, it is important to understand the risks and
benefits of each technique, and herein we evaluate the outcomes of each.
Our approach to these patients has been to reserve arch replacement for
those who have arch aneurysmal disease, imminent risk of rupture, or
cerebral malperfusion, and perform a hemiarch replacement in all other
scenarios with arch involvement. Such approach is easily taught, safe,
and reproducible while focusing more on survival rather than long-term
freedom from reintervention.