Operative technique
All patients who presented with ATAAD underwent emergent repair. Central
aortic cannulation, the preferred approach at our institution, was
performed utilizing a modified Seldinger technique, with transesophageal
echocardiographic (TEE) guidance to ensure cannulation of the true
lumen. Peripheral cannulation was performed if any of the following
contraindications to central cannulation were present: arch rupture,
complex primary or secondary arch tear, or complete circumferential arch
dissection [8]. When peripheral cannulation was required, right
subclavian artery cannulation through a silo graft was preferred over
femoral cannulation. Hypothermic circulatory arrest was employed
routinely, and patients were cooled to electroencephalogram (EEG)
silence [9]. The default repair strategy involved hemiarch
replacement with retrograde cerebral perfusion (RCP). Total arch
replacement with antegrade cerebral perfusion (ACP) was performed if any
of the following pathologies were present: 1) primary or secondary arch
tear, 2) circumferential arch dissection, 3) arch aneurysm, or 4)
carotid dissection resulting in cerebral malperfusion. Finally, a frozen
elephant trunk was performed in any cases of distal arch tear at or
beyond the origin of the left subclavian, severe pseudocoarctation,
and/or significant dilation of the proximal descending aorta with
concern for disruption [10,11,12].