How I Do It: Zone 2 Arch With Sequential Single-Branch TEVAR for Acute Type A Aortic Dissection

Acute DeBakey I aortic dissection often necessitates emergent repair, but conventional hemiarch replacement may leave residual tears in the arch or descending aorta, increasing the risk for future complications. Hybrid strategies that integrate open and endovascular techniques are emerging as viable solutions. The Supplemental Video presents a single case using a 2-stage hybrid approach: zone 2 arch replacement followed by single-branch thoracic endovascular aortic repair (TEVAR) to treat complex dissection anatomy.

A middle-aged patient presented in the hyperacute phase (<12 h) with chest pain and imaging consistent with DeBakey I dissection. In addition to a primary root/ascending tear, fenestrations located distal to the left subclavian artery (LSCA) were also present.

The initial operation involved open zone 2 arch replacement using a 2-branch surgical graft (12 mm limb for the innominate, 8 mm for the left carotid). The arch anastomosis was performed between the left carotid and LSCA, with the creation of a future endovascular landing. Unilateral antegrade cerebral perfusion was used for cerebral protection.

Following recovery, a second-stage endovascular repair was performed using a single-branch thoracic endograft. The main aortic graft was deployed into the surgical graft, and the side branch cannulated the LSCA. The repair was extended distally with a standard thoracic endograft to promote aortic remodeling. Completion angiography confirmed proper deployment, true lumen flow, and branch patency.

The patient had an uneventful recovery without neurologic deficits or spinal cord ischemia. Postoperative imaging confirmed exclusion of the primary tear, false lumen thrombosis in the thoracic aorta, and maintained perfusion of the supra-aortic vessels.

This case illustrates a safe and effective hybrid approach for complex acute type A dissection. The zone 2 arch repair simplifies the arch reconstruction and facilitates a secure proximal landing zone for branched TEVAR. This strategy avoids a deep anastomosis in zone 3 and allows staged, complete thoracic aortic treatment with excellent technical and clinical outcomes.