"Head First" approach streamlines aortic arch replacement

The "Head First" graft technique has emerged as a preferred approach for aortic replacement by many surgeons. This study evaluated its performance and safety, focusing on operative efficiency, cerebral protection, and its role in open arch repair outcomes.

We reviewed 150 patients who underwent zone 2 or more extensive arch replacement using the "Head First" approach from August 2020 to March 2025. Perioperative variables were compared between patients with acute type A aortic dissection (n = 40) and elective repair (n = 84). Logistic regression identified risk factors for stroke.

Patients' median age was 62 [49-69] years, and 64.7% were male. A total of 44% cases were urgent/emergent; 46.7% of patients underwent redo sternotomy, and 77.3% of patients received the frozen elephant trunk procedure. Nadir temperature was 27.4 °C [26 °C-28 °C]. Overall disabling stroke and 30-day mortality were 10.7% and 16.7%, respectively. Compared with elective patients, patients with acute type A aortic dissection had longer bypass (223.5 vs 156 minutes, P < .001) and circulatory arrest (24 vs 16 minutes, P < .001), and more prolonged intubation (65% vs 26.2%, P < .001) and 30-day mortality (40% vs 6%, P < .001). Disabling stroke rates were not significantly different (17.5% vs 8.3%, P = .219), and 3-year cumulative incidence of unplanned reintervention was similar. Male gender was independently protective against stroke (adjusted odds ratio, 0.34, P = .034). In univariable analysis, diabetes was a risk factor for stroke (odds ratio, 3.84, P = .046), whereas age (odds ratio, 1.03, P = .072) and frozen elephant trunk (odds ratio, 7.29, P = .057) showed borderline associations.

The "Head First" approach demonstrated acceptable outcomes in complex arch replacement. It prioritizes cerebral protection, facilitates timely reconstruction with shorter circulatory arrest, and may improve technical feasibility.