Extent of Aortic Replacement in Type A Dissection: Current Answers for an Endless Debate

Background: The proximal and distal extent of surgery for type A dissection is the subject of this review article. Methods: In this review, we summarize select series that illumine the issue at hand and provide insight into the surgical approach at our institution to DeBakey type I aortic dissections. Results: For proximal extent, we discuss preservation of the aortic valve in the presence of aortic insufficiency and management of the aortic root in the setting of root dilation. Distal extent of surgery for type A dissection has been a much more controversial topic. At our institution, we subscribe to the philosophy of ascending or hemiarch replacement alone for dissection under most circumstances. We describe when we believe a more aggressive arch replacement for type A dissection may be considered and detail the reports of other groups that have performed this operation more routinely. We also touch on the frozen elephant trunk operation and its role in type A dissection, although we believe it should be reserved for high-volume dedicated aortic centers. Finally, we conclude by discussing the role of experience in choosing aortic operations for type A dissection. Conclusions: In our opinion, there is no single correct operation for a patient with type A dissection, but there is a correct operation for each surgeon and clinical scenario.