Comparison of the Proximalized Distal Aortic Arch Anastomosis Site

Total arch repair (TAR) has traditionally been performed with a zone 3 distal anastomosis. In recent years, proximalization of the distal anastomosis has been utilized with proposed benefits including an easier distal anastomosis, reduced risk of bleeding, and lower rates of recurrent laryngeal nerve injury. While there have been several comparisons between more proximal distal anastomoses and the traditional zone 3 anastomosis, there have been limited comparisons between proximal anastomoses in zones 0-2. TAR with a frozen elephant trunk (FET) in zone 0 or 1 generally requires debranching of the head vessels proximally or a combination of head vessel bypasses with deployment of the FET across the aortic arch. Select hybrid arch FET devices are available in trifurcated configurations specifically made for a zone 0 distal anastomosis. A zone 2 arch can often be performed with a branched or straight graft and with head vessel anastomoses in the aortic arch. In four studies published to date comparing outcomes following proximal (zone 0/1) or more distal (zone 2) anastomoses, the majority of outcomes, including mortality, stroke, and aortic remodeling, were not significantly different. Rates of major bleeding were more common with a zone 2 distal anastomosis. Proximalization of the distal anastomosis at the time of TAR carries several benefits. Rates of bleeding were lower with a more proximal anastomosis, suggesting improved safety with a zone 0 or 1 anastomosis, without added risk in other metrics.