Reply to Glauber et al.

We thank Glauber et al. for their valuable comment to our article on prophylactic repair of aortic arch for acute type A aortic dissection.

The limited ascending aortic or hemiarch replacement is widely accepted for permitting a primary goal of immediate survival by preventing secondary cardiac events [1]. However, in the long-term, repeated surgery for the residual dissection of the arch, descending thoracic aorta, and abdominal aorta would be necessary in some instances. Therefore ‘tear-oriented surgery’ has been widely recommended because complete resection of the primary tear is a key to good early- and long-term outcomes. The indications of total arch replacement combined with the frozen elephant trunk procedure are (1) tear in the descending aorta (‘retrograde dissection’), (2) tear in the arch (excluding the minor curvature), (3) massive arch dissection, (4) arch aneurysm or dilatation, (5) relatively young age less than 70 years, and (6) Marfan syndrome.

Remaining tear near the left subclavian artery induces poor prognosis on the distal aorta [2]. Remaining tear near the left subclavian artery occurs because of anastomotic leak or second tear caused from the dissection of the internal costal artery that directly diverges from descending thoracic aorta. Hybrid treatment using frozen elephant trunk has the purpose to prevent anastomotic leak and close tears near the left subclavian artery. We think it is enough to accomplish the purpose and safe without a supplementary risk in the insertion to the Th 7 level [3]. Moreover, endovascular stent graft repair via femoral artery can be easily performed in the second stage if the descending thoracic aorta of the line to the Th 7 level is substituted. Use of a stent graft for acute dissection has the risk of intimal damage and selection of size is controversial. We want to emphasize that direct sizing through an incision in the aortic arch is very important. We insert a ball-shaped valve sizer into the true lumen of the descending aorta from the transverse incision under transesophageal ultrasound guidance and choose the correct size.

Prophylactic aortic arch debranching technique during type A aortic dissection repair might allow a safe and effective endovascular treatment via femoral artery in the chronic phase. However even if only the primary tear is closed for the descending aorta with a residual false lumen that has been expanded in the chronic phase such as after 3 years, the descending thoracic aorta enlargement cannot be prevented because of multi tears in thoraco-abdominal aorta [4]. It is necessary to recommend secondary endovascular stent graft repair before the remaining false lumen expands.

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