Operative technique
All patients who presented with ATAAD underwent emergent repair. Central aortic cannulation, the preferred approach at our institution, was performed utilizing a modified Seldinger technique, with transesophageal echocardiographic (TEE) guidance to ensure cannulation of the true lumen. Peripheral cannulation was performed if any of the following contraindications to central cannulation were present: arch rupture, complex primary or secondary arch tear, or complete circumferential arch dissection [8]. When peripheral cannulation was required, right subclavian artery cannulation through a silo graft was preferred over femoral cannulation. Hypothermic circulatory arrest was employed routinely, and patients were cooled to electroencephalogram (EEG) silence [9]. The default repair strategy involved hemiarch replacement with retrograde cerebral perfusion (RCP). Total arch replacement with antegrade cerebral perfusion (ACP) was performed if any of the following pathologies were present: 1) primary or secondary arch tear, 2) circumferential arch dissection, 3) arch aneurysm, or 4) carotid dissection resulting in cerebral malperfusion. Finally, a frozen elephant trunk was performed in any cases of distal arch tear at or beyond the origin of the left subclavian, severe pseudocoarctation, and/or significant dilation of the proximal descending aorta with concern for disruption [10,11,12].