Total Aortic Arch Replacement

We review the operative techniques of aortic arch replacement. Aortic arch replacement presents several formidable challenges, as it requires arresting the circulation to the body and replacement of the brachiocephalic vessels with special consideration for protecting the central nervous system. Perfusion strategies, selective antegrade cerebral perfusion, and operative graft selection are key elements in aortic arch replacement surgery. Standard approaches include the island technique, the branched graft technique, and the “Spielvogel” trifurcated graft technique—each having its own advantages. In addition, thoracic aortic aneurysms involving the arch and descending aorta pose a substantial surgical challenge and often require hybrid or nonclamp technique with staged operative interventions. Hybrid and endovascular (thoracic endovascular aortic repair) techniques for the descending aorta are evolving and require consideration in operative planning. Areas of controversy include management of the subclavian artery, extent of distal arch replacement, elephant trunk and hybrid frozen elephant trunk techniques, and use and timing of staged approaches. Aortic arch replacement remains a complex, potentially difficult procedure. Better understanding of the potential open approaches to arch replacement will optimize the potential outcomes for patients. Aortic arch pathology is best served by tailoring the procedure to the patient-specific anatomy and pathology.