Innovations in aortic disease: the ascending aorta and aortic arch

Significant innovations have defined the approach to the proximal thoracic aorta. Aortic proteolysis predisposes to dissection and aneurysm. Losartan may prevent aortic root dilation in Marfan syndrome. The Loeys-Dietz syndrome mandates early aortic intervention. Because genetic aortopathies have a multicenter registry, further aortic molecular advances are likely. Acute intramural hematoma (IMH) may be due to aortic dissection with unrecognized microintimal tears. Type-A IMH is often a surgical emergency, whereas type-B IMH often requires medical management. Because preoperative ischemia predicts mortality in type-A dissection, it is logical to classify this disease by ischemic presentation. Because advanced age worsens the outcome in type-A dissection, transcatheter interventions should be urgently developed for this high-risk subgroup. Aortic arch repairs shorter than 45 minutes in duration are safely performed under deep hypothermic circulatory arrest with/without perfusion adjuncts. Bilateral antegrade cerebral perfusion (ACP) offers the best neuroprotection for complex repairs longer than 45 minutes. Axillary artery cannulation improves outcomes in proximal thoracic aortic procedures. Contralateral hemispheric ischemia is possible with unilateral ACP because cross-cerebral perfusion may be inadequate. Arch repair with ACP and moderate HCA is safe and effective and represents a research opportunity for pharmacologic ischemic preconditioning. Antegrade thoracic aortic stenting for DeBakey 1 dissection thromboses the distal false lumen to improve long-term aortic outcomes. Endovascular arch repair is feasible and may soon be done off-pump. These described innovations have collectively ushered in a paradigm shift in diseases affecting the ascending aorta and aortic arch.