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Aim The benefits of BioGlue as a surgical adjunct in aortic procedures have been demonstrated in several studies, but limited information is available regarding the associated histopathological findings of aortic tissue at the time of reoperation. The objective of this study was to assess, at reoperation, the histopathological characteristics of aortic tissue which has had BioGlue applied during a previous surgery. Methods This prospective, single-center, single-arm study enrolled patients who were undergoing aortic reoperation and who had BioGlue used during previous aortic surgery. Histopathological assessment of aortic specimens obtained intraoperatively was performed on tissue that would have been removed independent of subject participation in the study. Results A total of 11 patients were enrolled and based on gross assessment, excessive amounts of BioGlue had been applied during the initial surgery in 36.4% of cases. The samples with the greatest amount of residual BioGlue demonstrated moderate to marked inflammatory responses, while the remaining samples demonstrated minimal to moderate inflammatory responses. Calcification of residual BioGlue was noted in 4 cases. Substantial medial degeneration was associated with suture line dehiscence in 4 cases, some of which had a large quantity of residual BioGlue. No evidence of suture degradation was observed. Conclusions Cases with surgical anastomosis dehiscence were associated with substantial medial degeneration. While no histologic findings directly linked BioGlue to these degenerative changes, a contributory role cannot be excluded. Following the manufacturer's instructions for appropriate application of BioGlue is crucial to prevent potential complications.

Selective antegrade cerebral perfusion technique is a method of cerebral protection used worldwide during aortic arch surgery. This study was designed to identify a potential correlation between perfusion flows and the development of postoperative transient neurological dysfunctions.From January 2015 to May 2020, 175 patients underwent elective surgical replacement of the aortic arch using selective antegrade cerebral perfusion at the Cardiac Surgery Unit of Sant'Orsola Hospital in Bologna. Considering that patients who developed a permanent neurological dysfunction and those who died before a possible evaluation of neurological status were excluded, the study population included 160 patients. The perfusion flows were collected and analyzed. Univariate and multivariate analyses were performed to identify the statistical risk factors involved in the onset of transient neurological dysfunctions.The study population was divided into two groups: 138 patients (86.3%) without and 22 (13.8%) with postoperative transient neurological complications. Among the intra-operative parameters collected in the study, the univariate analysis showed that the indexed medium perfusion flow of selective antegrade cerebral perfusion was significantly lower in the transient neurological dysfunctions group (11.63 ± 2.41 ml/kg/min vs 12.62 ± 2.39 ml/kg/min, P -value = 0.03). The multivariate logistic regression analysis showed that the female gender ( P = 0.004, OR = 4.816, IC = 1.636-14.174) was predictor of transient neurological dysfunctions.The results of the study showed that lower perfusion flows seem to be related to a higher probability of developing transient neurological dysfunctions. However, the analysis of a wider population is required to confirm these preliminary data.

Revascularization of the left subclavian artery (LSA) is considered a method of spinal cord protection from ischemia during thoracic endovascular aortic repair (TEVAR). Coverage of the artery of Adamkiewicz with TEVAR is usually well tolerated because of collateral pathways to this vessel, but on the other side, the LSA is crucial in this regard since it represents the primary source of collateral pathways. In our commentary, we wish to focus the discussion on the LSA revascularization and about the complexity of the anatomy of spinal cord supply in order to underline what have been already studied, analyzed, and recommended from the current guidelines.

Background Bradyarrhythmias requiring pacemaker implantation (PM) in patients undergoing valve surgery may occur even after several years. The incidence of PM implantation after valve surgery and its predictors are unclear. Methods A retrospective, monocentric, cohort study was conducted. Consecutive patients undergoing valve surgery at the Division of Cardiac Surgery at the Bologna University Hospital from 2005 to 2010 were enrolled. The primary endpoint of the study was to evaluate the incidence of PM implantation in patients undergoing valve surgery, at different follow-up times, and to evaluate the predictors of PM implantation. Results We included 1046 patients (61.8% male, median age 63 years). Of these 735 (70%) reached a 10 year of follow-up and 11.4% required PM implantation. In single valve surgery, mitral interventions had a higher incidence of PM implantation compared to aortic ones, albeit not significantly different (11% vs 8.1%, HR 1.2, IC 95% 0.6-2.1, p=0.590). Among combined surgery, interventions on both atrioventricular valves doubled the risk compared to those performed on aortic and mitral valves (23.1% vs 12%). Moreover, interventions involving both atrioventricular valves independently predicted PM implantation in the long term (HR 2.0, IC 95% 1.1-3.7, p=0.022). Preoperative atrioventricular conduction disease strongly predicted long-term atrio-ventricular block: right bundle branch block with or without left anterior fascicular block (LAFB) was the major predictor (HR 7.2, IC 95% 2.8-19, p Conclusions Patients undergoing valvular surgery have a continuing risk of atrioventricular block requiring PM therapy late after surgery; combined surgery on atrio-ventricular valves carries the highest risk, while preoperative atrioventricular conduction disease have different risks of AVB at long-term.

Aberrant right subclavian artery (ARSA) is a relatively rare congenital anomaly of the aortic arch. A 74-year-old woman was referred to our Cardiac Surgery Department for chest pain. Angio-CT scan showed an acute aortic dissection and revealed an ARSA routed behind the trachea. We performed supra-coronary ascending aorta and total arch replacement with Frozen Elephant Trunk (FET) technique. The ARSA was then termino-terminal anastomosed to one branch of the Thoraflex arch graft. Postoperative CT-scan indicated a successful reconstruction of the aortic arch, proving the open stent-grafting technique as a useful and effective approach for aortic disease with ARSA.

Objectives The introduction of selective antegrade cerebral perfusion technique as method of cerebral protection improved the outcome of open arch surgery. The aim of this study was to report early outcomes using this technique. Methods Between 1997 and 2017, data were collected retrospectively for all patients who underwent surgical replacement of the aortic arch using selective antegrade cerebral perfusion ( n = 938). To confirm the effectiveness of this cerebral protection method, early outcome and results were evaluated. Results The incidence of postoperative permanent neurological dysfunction was 6.4%. Overall hospital mortality was 11.9% ( n = 112). On multivariable analysis, age >75 years, female gender, euroscore at increment of 1 point, chronic renal failure, extension of thoracic aorta replacement and CPB time emerged as independent risk factors for hospital mortality. The mid-term survival at 1, 5, 10 and 15 years was 92%, 78%, 60% and 49%, respectively. The competing risk analysis for permanent neurological dysfunction and aortic reoperations was performed excluding the patients who died during the hospital stay. The cumulative incidence of permanent neurological dysfunction and aortic reoperations was 2% at 3 years, 3% at 5 years, 6% at 10 years, 12% at 3 years, 15% at 5 years and 19% at 10 years, respectively. Conclusions From the early 90s to the present day, the selective antegrade cerebral perfusion has confirmed to be a useful and “safe” method of brain protection in aortic arch surgery in terms of postoperative neurological complications.

Background The aims of this study were to analyse the incidence of visceral malperfusion syndrome (MPS) following Frozen Elephant trunk operations in patients affected by chronic aortic dissection and the associated risk factors. Methods Between January 2007 and February 2019, 165 patients underwent surgery with FET for chronic aortic dissection. Post-operative computer tomography angiogram parameters (diameters, early post-operative false lumen enhancement and involving of aortic branches by the dissection) were collected and analysed to evaluate their impact on the occurrence of visceral malperfusion. Results Visceral (renal and mesenteric) MPS (with both clinical and radiological signs of MPS) was detected in 10 cases (6.1%). Post-operative visceral malperfusion was strongly related with in hospital mortality. The involvement of the visceral branches in the dissection was not a risk factor for visceral malperfusion occurrence, while a larger post-operative total aortic diameter at level of the coeliac trunk increased the risk of visceral MPS (OR 1.05; CI 1.002–1.102, p-value = 0.04). Furthermore, visceral MPS was associated to a complete thrombosis of the false lumen at level of the distal descending thoracic aorta. Conclusions The development of post-operative MPS in frozen elephant trunk is strongly related to in-hospital mortality. The involvement of aortic branches by the dissection does not represent a real predictive risk factor for MPS, while early larger aortic diameters and false lumen thrombosis represent independent risk factors for MPS and in-hospital mortality.

The study objective was to analyze the outcomes of reoperative thoracic aortic surgery at our institution from January 1986 to December 2018 to identify specific risk factors for early and late mortality.Two groups of patients were identified: aortic root or ascending aorta repair (group 1: proximal repair, 218 patients, 48%) and arch surgery or descending thoracic aorta repair (group 2: distal repair, 235 patients, 52%). Primary end points were 30-day mortality, 10-year survival, and freedom from aortic reoperations.The 30-day mortality (6.4% vs 8.1%) and in-hospital mortality (8.3% vs 11.9%) were similar (P .05) in the 2 groups. Multivariable analysis identified female gender (odds ratio, 8.60, P .01), endocarditis (odds ratio, 2.96, P = .04), and cardiopulmonary bypass time (odds ratio, 1.02, P .01) as risk factors for 30-day mortality. Mean follow-up time was 163 months (confidence interval, 147-179). Long-term survival at 1, 5, and 10 years was 91.2%, 79.4%, and 66.3% in the proximal repair group and 80.7%, 68.8%, the and 55.3% in distal repair group, respectively (P = .03). According to the indication, 1-, 5-, and 10-year survivals were 92.1%, 82.3%, and 68.8% in degenerative aneurysms; 82.7%, 72.4%, and 56.3% in residual dissections; 80.9%, 65.4%, and 50.3% in endocarditis and pseudoaneurysms; 69.2%, 52.7%, and 42.2% in acute type A aortic dissections, respectively (P .01). Competing risk analysis showed a significantly different cumulative incidence of reoperation at 1, 5, and 10 years between the 2 groups: 0.50%, 0.50%, and 0.90%, respectively, for the proximal repair group, and 0.40%, 4.30%, and 7.70%, respectively, the for distal repair group (P .01).In our experience, short- and long-term results of reoperative thoracic aortic surgery were satisfactory in chronic aneurysms but poor in aortic dissections, pseudoaneurysms, and active endocarditis. Reoperative aortic surgery carries a high risk, regardless of the anatomic extension of the procedure.

Background: The aim of this multicenter prospective study was to evaluate the prognostic weight of preoperative right ventricular assessment on early mortality in cardiac surgery. Methods: This is a multicenter prospective observational study performed by the Italian Group of Research for Outcome in Cardiac Surgery (GIROC) including 11 centers. From October 2017 to March 2019, out of 923 patients undergoing cardiac surgery, 28 patients with some missing data were excluded and 895 patients were enrolled in the study right ventricular dilatation was defined as a basal end-diastolic diameter >42 mm. The right ventricle (RV) function was assessed using the combination of three parameters: fractional area changing (FAC), tricuspid annular plane systolic excursion (TAPSE), and S'-wave using tissue Doppler imaging (TDI-S'); RV dysfunction was defined as the presence of at least two of the following cutoffs: FAC

Fractional flow reserve (FFR) is the ratio of distal to proximal pressure during maximal hyperemia and indirectly estimates the blood flow across a stenotic coronary artery and the related degree of myocardial ischemia. Several studies have investigated the role of FFR in the setting of percutaneous myocardial revascularization and further research is ongoing. However, current evidence on FFR-guided surgical myocardial revascularization is controversial and limited. The main scientific interest is to clarify whether FFR-guided coronary artery bypass surgery is associated with clinical benefits in terms of mortality, myocardial infarction, major adverse cardiovascular events, minimally invasive surgical access compared with sternotomy and off-pump surgery. Furthermore some data suggest that conduit selection for coronary artery bypass grafting and surgical technique might be affected by FFR value. The aim of this article is to review the most recent available evidence about FFR-guided coronary artery bypass grafting and to discuss clinical implications and future perspectives.

Cardiac masses encompass a wide spectrum of clinico-pathological entities, including benign and malignant—both primary and secondary—tumours.1,2 A fourth, extremely heterogenous subgroup, is represented by pseudo-tumours,3,4 which are non-neoplastic lesions—such as thrombi, calcifications, cysts, or valvular nodules—not included in the current World Health Organization classification of cardiac tumours.2 It appears, therefore, essential to correctly address the masses’ nature in order to identify the ideal therapeutic management.5

The treatment of complex aortic arch disease, in chronic or acute setting, has always represented a fascinating challenge for the heart surgeon also because, often, the involvement of the aortic arch is associated with a simultaneous involvement of the ascending aorta and of the proximal portion of the descending thoracic aorta. In recent years, there have been many surgical and/or endovascular techniques and approaches in a single step or multiple steps proposed with the aim of treating and simplifying these complex conditions. The first procedure available for this purpose was the conventional elephant trunk technique, proposed by the German surgeon Hans Borst, back in 1983. In the following years, the technique has undergone modifications, up to what is nowadays considered its most modern evolution, represented by the frozen elephant trunk which allows managing the proximal descending thoracic aorta using the antegrade release of a self-expandable stent graft. In this review article, we try to analyze the advantages and drawbacks of both techniques from clinical and practical points of view.

The decision-making process is crucial for the surgery of acute type A aortic dissection (AAAD). Often surgeons have to face different challenges, taking prompt decisions in emergency setting, during the pre- and intraoperative phase. Choosing if operate or not a patients with AAAD as well as the management of the dissected aortic arch can be challenging. Different factors need to be evaluated as: the patients age, the presence of organ malperfusion, the intimal tear location, and last but not least the surgeon personal experience in aortic surgery. During the last decade, different milestone steps have been achieved in aortic surgery as the antegrade perfusion of the aorta through different cannulation sites, open distal repair, antegrade selective cerebral perfusion, and systematic resection of the proximal intimal tear, allowing complex repair for dedicated team as well as simpler repair for not dedicated surgeons. We reviewed different scenarios and techniques used for the aortic arch replacement in patients with AAAD, taking into consideration that the aim of surgery is to save patients life.

Although the endovascular approach is the therapeutic option of choice for thoracic and abdominal aortic diseases, open surgery is still the treatment of choice for aortic arch diseases. While open surgical repair remains the gold standard treatment for complete aortic arch replacement, it continues to be burdened by high mortality and neurologic complications, especially for patients who require redo surgery. Therefore, in the era of endovascular surgery, it is not surprising that hybrid operating rooms, new technologies, and new approaches are strongly challenging open surgery. Less-invasive endovascular procedures, when used to treat aortic arch diseases, when feasible and indicated, have clear advantages over open surgery, primarily because there is no need for cardiopulmonary bypass, hypothermic circulatory arrest, or cerebral protection. Moreover, patients who have already been treated for acute type A aortic dissection continue to have a considerable risk for future aortic reintervention, which is associated with increased risk for short- and long-term mortality. In light of these advantages, it is clear how selected high-risk patients with aortic arch disease could benefit from the endovascular approach. However, the hemodynamic and anatomic characteristics of the aortic arch make the endovascular approach in this region challenging. In fact, uncorrected stent-graft placement can have fatal consequences for the patient and increase the risk of endoleaks and stroke. To minimize these potential risks, precise and accurate preoperative planning to achieve optimal stent-graft dimensions and implantation is essential together with careful patient selection. Endovascular options for the treatment of aortic arch disease include both hybrid procedures and total endovascular solutions. This manuscript provides an overview of the current strategies for endovascular aortic arch treatment, including the most recent available series on this topic. In addition, a literature search offers insight into the current state of the art.

The study objective was to evaluate the surgical results in patients with acute type A aortic dissection and cerebral malperfusion.From 2000 to 2019, 234 patients with type A aortic dissection and cerebral malperfusion were stratified into 3 groups: 50 (21%) with syncope (group 1), 152 (65%) with persistent loss of focal neurological function (group 2), and 32 (14%) with coma (group 3). Results were evaluated and compared by univariable and multivariable analyses.Median age was higher in group 1, and incidence of cardiogenic shock was higher in group 3. The femoral artery was the most common cannulation site, whereas the axillary artery was used in 18% of group 1, 30% of group 2, and 25% of group 3 patients (Patients with aortic dissection and cerebral malperfusion without preoperative coma showed acceptable mortality, and those with coma had a high in-hospital mortality regardless of the type of brain protection. Overall axillary artery cannulation appeared to be a protective factor.

OBJECTIVES The aim of this study was to evaluate the effects of the coronavirus 2019 pandemic on elective and acute thoracic aortic surgery in the Netherlands. METHODS The Netherlands Heart Registration database was used to compare the volume of elective and acute surgery on the thoracic aorta in 2019 and 2020, starting from week 11 in both years. A sub-analysis was done to assess the impact of the pandemic on high-volume and low-volume aortic centres. RESULTS During the pandemic, the number of elective thoracic aortic operations declined by 18% [incidence rate ratio (IRR) 0.82 [0.73–0.91]; P < 0.01]. The decline in volume of elective surgery was significant in both high-volume (IRR 0.82 [0.71–0.94]; P < 0.01) and low-volume aortic centres (IRR 0.81 [0.68–0.98]; P = 0.03). The overall number of acute aortic operations during the pandemic remained similar to that in 2019 (505 vs 499; P = 0.85), but an increased share of these operations occurred at high-volume centres. The number of acute operations performed in high-volume centres increased by 20% (IRR 1.20 [1.01–1.42]; P = 0.04), while the number of acute operations performed in low-volume centres decreased by 17% (IRR 0.83 [0.69–1.00]; P = 0.04). CONCLUSIONS The coronavirus 2019 pandemic led to a significant decrease in elective thoracic aortic surgery but did not cause a change in the volume of acute thoracic aortic surgery in the Netherlands. Moreover, the pandemic led to a centralization of care for acute thoracic aortic surgery., The coronavirus disease 19 (COVID-19) pandemic has impacted the delivery of health care around the world.

In patients with operated type A aortic dissections, irreversible spinal cord injury (SCI) may result from several factors: prolonged circulatory arrest, extension of replacement, and hypoperfusion of segmental arteries secondary to aortic false lumen thrombosis. Careful neuroprotective strategies and shorter operative times are crucial to reduce SCI incidence. Despite optimal perioperative management, delayed-onset SCI occurs in rare cases in response to subacute aortic remodeling. This report describes the case of a 77-year-old woman who underwent ascending aorta and hemiarch replacement for type A aortic dissection and had delayed paraplegia that developed on postoperative day 12.

OBJECTIVES A heart transplant (Htx) remains the gold standard treatment for patients with advanced heart failure. Considering the limited availability of organs, donor risk scores might improve organ selection and allocation. The objective of the study was to compare United Network for Organ Sharing, RADIAL and Eurotransplant scoring models in calculating post-Htx outcomes in an Italian Htx population. METHODS Between January 2000 and December 2017, a total of 461 adult patients underwent Htxs. United Network for Organ Sharing, RADIAL and Eurotransplant scores were calculated. Clinical features and donor risk scores were tested to identify preoperative, intraoperative and postoperative risk variables and eventually validate the scores on our population. RESULTS Early graft failure was detected in 16.1% (74/461). Post-Htx extracorporeal life support was used in 11.1% (51/461). Of the donor-related factors, the use of noradrenaline (P = 0.015) negatively influenced early outcomes, whereas an ischaemic time >240 min (P = 0.037) influenced early graft failure occurrence. The Eurotransplant donor score did not impact outcomes; the RADIAL score significantly influenced both early and late mortality; and the United Network for Organ Sharing score influenced only late mortality. On the multivariable analysis, after adjustment of scores per cohort, noradrenaline infusion was the main independent predictor of in-hospital mortality for the donors, whereas age of the recipient [odds ratio (OR) 1.003, 1.003–1.081; P = 0.032] and use of preoperative extracorporeal membrane oxygenation (OR 3.320, 1.124–9.805; P = 0.030) were the main independent predictors for the recipients. CONCLUSIONS None of the validated donor scoring systems fully behave as reliable predictors of transplant outcomes. According to our ‘local only’ graft selection, specific donor and recipient risk variables should be monitored in order to predict early and late outcomes satisfactorily.

The term "acute aortic syndrome" describes a variety of acute and emerging aortic pathologies that include intramural hematoma, penetrating aortic ulcer and acute aortic dissection. However, the acute pathology of the thoracic aorta also includes the contained ruptures of aortic aneurysms, traumatic aortic ruptures and iatrogenic aortic dissections. In all these acute situations, in which emerging surgical treatment is often required, decision-making represents a crucial and extremely important phase, which often affects the patient's prognosis, in the short and long term. This review aims to present an update of the surgical treatment of acute aortic syndrome focusing mainly on the correct decision-making, the factors that influence it and the latest novel surgical techniques and strategies.

An anomalous origin of the left circumflex coronary artery that arises as a side branch of the right coronary artery and encircles the aortic annulus is usually an incidental finding. However, in patients undergoing aortic valve/root procedures, its existence can significantly complicate the surgical treatment. We report our operative strategy with three different prostheses without valve downsizing.

We present a case of a patient, who had previously undergone a frozen elephant trunk procedure for acute non-A–non-B aortic dissection, and developed a traumatic new entry tear due to the displacement of the hybrid prosthesis while skiing. An emergency thoracic endovascular aortic repair was performed without postoperative complications.

BACKGROUND: Patients with liver cirrhosis (LC) undergoing cardiac surgery (CS) face perioperative high mortality and morbidity, but extensive studies on this topic are lacking.METHODS: All adult patients with LC undergoing a CS procedure between 2000 and 2017 at 10 Italian Institutions were included in this retrospective cohort study. LC was classified according to preoperative Child-Turcotte-Pugh (CTP) score and Model for End-Stage Liver Disease (MELD) score. Early-term and medium-term outcomes analysis was performed in the overall population and according to CTP classes.RESULTS: The study population included 144 patients (mean age 66 ± 9 years, 69% male). Ninety-eight, 20, and 26 patients were in CTP class A, in early CTP class B (MELD score 12), respectively. The main LC etiologies were viral (43%) and alcoholic (36%). Liver-related clinical presentation (ascites, esophageal varices, and encephalopathy) and laboratory values (estimated glomerular filtration rate, serum albumin, and bilirubin, platelet count) significantly worsened across the CTP classes (P= .001). Coronary artery bypass grafting or valve surgery (87% bioprosthesis) were performed in 36% and 50%, respectively. Postoperative complications (especially acute kidney injury, liver complication, and length of stay) significantly worsened in advanced CTP class B (P= .001). Notably, observed mortality was 3-fold or 4-fold higher than the EuroSCORE (European System for Cardiac Operative Risk Evaluation) II-predicted mortality, in the overall population, and in the subgroups. At Kaplan-Meier analysis, 1-year and 5-year cumulative survival in the overall population was 82% ± 3% and 77% ± 4%, respectively. The 5-year survival in CTP class A, early CTP class B, and advanced CTP class B was 72% ± 5%, 68% ± 11%, and 61% ± 10%, respectively (P= .238).CONCLUSIONS: CS outcomes in patients with LC are significantly affected in relation to the extent of preoperative liver dysfunction, but in early CTP classes, medium-term survival is acceptable. Further analysis are needed to better estimate the preoperative risk stratification of these patients.

This study aimed to investigate the potential association between imaging features and cardiovascular outcomes in patients with Loeys-Dietz syndrome (LDS). We performed a retrospective cohort study of 36 patients with LDS and described cardiovascular events and imaging data. We observed different clinical courses in patients with LDS, irrespective of the causative gene. Angular or elongated aortic arch geometry correlated with aortic dissection (R = .39, p = .02), occurrence of the first cardiovascular event before 45 years of age (R = .36, p = .03), and the number of operations (R = 0.47, p = .004), but not with age (R = -.05, p = .79) or the causative gene (R = -0.04, p = .79). The incidences of first cardiovascular events at ages 20, 40, and 60 years were 100, 75, and 56%, respectively, in patients with normal aortic arches, and 74, 39, and 21%, respectively, in patients with angular or elongated aortic arches (log-rank p = .03). Angular or elongated aortic arch geometry is associated with early-onset of disease and a worse cardiovascular outcome in LDS patients. Large multicenter studies are warranted to elucidate the impact of aortic arch morphology evaluation in clinical practice.

Since its clinical implementation in the late nineties, thoracic endovascular aortic repair (TEVAR) has become the standard treatment of several acute and chronic diseases of the thoracic aorta. While TEVAR has been embraced by many, this disruptive technology has also stimulated the continuing evolution of open surgery, which became even more important as late TEVAR failures do need open surgical correction justifying the need to unite both treatment options under one umbrella. This fact shows the importance of—in analogy to the heart team—aortic centre formation and centralization of care, which stimulates continuing development and improves outcome . The next frontier to be explored is the most proximal component of the aorta—the aortic root, in particular in acute type A aortic dissection—which remains the main challenge for the years to come. The aim of this document is to provide the reader with a synopsis of current evidence regarding the use or non-use of TEVAR in acute and chronic thoracic aortic disease, to share latest recommendations for a modified terminology and for reporting standards and finally to provide a glimpse into future developments.

The best surgical treatment for acute type A aortic dissection (AAAD) is still a strongly debated issue of every cardiac surgeon. The successful result is obtained by taking into consideration both the preoperative and intraoperative aspects, such as cerebral, visceral or coronary malperfusion before surgery. More conservative approaches or more aggressive treatments are different strategies with their pros and cons to face the same problem, especially for the aortic arch management. The expertise of the center, the perfect surgical timing and a dedicated aortic team composed of expert aortic surgeons, anesthesiologist, radiologist and cardiologist are important but not mandatory to achieve the best results in this type of surgery since is not possible to offer it in all the hospitals. The accurate assessment of the aortic anatomy has to be performed, including the extension of the dissection process, the exact location of the entry and re-entry tears, the aortic diameters, the distribution of visceral vessels between the true and the false lumen and the assessment of perfect size of the prosthesis to avoid the oversize since it may cause new entry site in the descending thoracic aorta. We reviewed and analyzed different scenarios and techniques used for the aortic arch replacement in patients with AAAD, taking into consideration that the aim of surgery is to save patients life.