Illustration of Aortic Arch

Total Aortic Arch Replacement: Is This Surgery Right for You?

Nico Varela in Health & Wellness August 2025 • 4 min read.

"A deep dive into a 15-year study on 1000+ patients undergoing total arch replacement (TAR) using a 4-branched graft with antegrade cerebral perfusion (ACP) to weigh the benefits, risks, and recovery insights."

The aortic arch, responsible for distributing blood from the heart to the brain and the rest of the body, can be vulnerable to life-threatening conditions like aneurysms and dissections. When these problems arise, total arch replacement (TAR) becomes a critical surgical consideration. But what does this procedure entail, and what are the factors to consider?

For over a century, surgeons have sought reliable ways to repair or replace the aortic arch. The challenge lies in safely managing the vital brachiocephalic branches that stem from the arch. A significant advancement in this area is the use of a 4-branched graft combined with antegrade cerebral perfusion (ACP). This technique aims to maintain blood flow to the brain throughout the procedure, reducing the risk of neurological complications.

This article explores TAR using a 4-branched graft with ACP, drawing on the findings of a 15-year study involving over 1000 patients. We'll delve into the procedure itself, analyze the outcomes, and discuss who might benefit most from this approach, especially in light of evolving, less invasive options.

Understanding the 4-Branched Graft TAR Procedure

The 4-branched graft technique represents a significant evolution in aortic arch surgery. Historically, surgeons faced the complex task of reconstructing the arteries branching off the aortic arch. Earlier methods, like the "island technique," were employed, where the openings for these arteries were patched together. However, the 4-branched graft offers a more direct and potentially safer solution.

In this procedure, the damaged section of the aortic arch is replaced with an artificial graft featuring four branches. These branches are then connected to the brachiocephalic artery, the left common carotid artery, and the left subclavian artery, ensuring continuous blood flow to the brain. This is where antegrade cerebral perfusion (ACP) becomes crucial. ACP involves delivering oxygenated blood directly to the brain during the surgery, minimizing the risk of stroke or other neurological issues.

Reduced Neurological Risk: ACP helps protect the brain during circulatory arrest.
Direct Reconstruction: The 4-branched graft allows for direct and secure connections to the arch vessels.
Established Technique: TAR with a 4-branched graft has become a standard surgical procedure in many centers.

The 15-year study highlighted the importance of careful patient selection and meticulous surgical technique. While TAR with a 4-branched graft can achieve acceptable outcomes, it's essential to acknowledge the potential risks and consider alternative approaches, especially for certain patient populations.

Is TAR the Right Choice in the Era of TEVAR?

While TAR with a 4-branched graft remains a viable option, especially for complex aortic arch pathologies, the rise of thoracic endovascular aortic repair (TEVAR) presents a significant alternative. TEVAR, a less invasive procedure, involves deploying a stent graft within the aorta to reinforce the weakened section. However, TEVAR may not be suitable for all patients, particularly those with extensive arch involvement or connective tissue disorders.

The decision between TAR and TEVAR requires careful consideration of the patient's overall health, the specific characteristics of the aortic arch disease, and the surgeon's expertise. In the study, octogenarians undergoing TAR had a higher risk of mortality, suggesting that TEVAR might be a more appropriate option for this age group when anatomically feasible.

Ultimately, the future of aortic arch surgery lies in personalized approaches, combining the strengths of both open surgical techniques and endovascular interventions to achieve the best possible outcomes for each patient. Further research and technological advancements will continue to refine these strategies, improving the safety and efficacy of aortic arch repair.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.jtcvs.2018.09.112, Alternate LINK

Title: Total Arch Replacement Using A 4-Branched Graft With Antegrade Cerebral Perfusion

Subject: Cardiology and Cardiovascular Medicine

Journal: The Journal of Thoracic and Cardiovascular Surgery

Publisher: Elsevier BV

Authors: Kenji Minatoya, Yosuke Inoue, Hiroaki Sasaki, Hiroshi Tanaka, Yoshimasa Seike, Tatsuya Oda, Atsushi Omura, Yutaka Iba, Hitoshi Ogino, Junjiro Kobayashi

Published: 2019-04-01

Everything You Need To Know

What exactly is total aortic arch replacement (TAR) and why is it performed?

Total aortic arch replacement (TAR) is a surgical procedure where the damaged aortic arch is replaced. The aortic arch distributes blood from the heart to the brain and body. A key technique involves using a 4-branched graft, which has four branches connected to the brachiocephalic, left common carotid, and left subclavian arteries, ensuring blood flow to the brain. Antegrade cerebral perfusion (ACP) is also used to deliver oxygenated blood directly to the brain during the surgery, reducing the risk of neurological complications. The procedure aims to address life-threatening conditions like aneurysms and dissections of the aortic arch.

How does the 4-branched graft with antegrade cerebral perfusion (ACP) protect the brain during aortic arch surgery?

The 4-branched graft with antegrade cerebral perfusion (ACP) is designed to reduce the risk of stroke or other neurological issues during total aortic arch replacement (TAR). The graft has four branches directly connected to the brachiocephalic artery, the left common carotid artery, and the left subclavian artery, ensuring continuous blood flow to the brain. ACP delivers oxygenated blood directly to the brain during circulatory arrest. This direct reconstruction of the arch vessels reduces the risk compared to older techniques.

How does total aortic arch replacement (TAR) compare to thoracic endovascular aortic repair (TEVAR)?

While total aortic arch replacement (TAR) with a 4-branched graft is a standard surgical procedure, thoracic endovascular aortic repair (TEVAR) is a less invasive alternative. TEVAR involves deploying a stent graft within the aorta to reinforce weakened sections. TEVAR might not be suitable for patients with extensive arch involvement or connective tissue disorders, making TAR a more appropriate option in those cases. The choice depends on the specific condition and the patient's overall health.

What did the 15-year study reveal about the outcomes of total aortic arch replacement (TAR) using a 4-branched graft?

The 15-year study involving over 1000 patients undergoing total aortic arch replacement (TAR) with a 4-branched graft and antegrade cerebral perfusion (ACP) highlighted the importance of patient selection and surgical technique. While the study indicated acceptable outcomes, it also stressed acknowledging potential risks and considering alternative approaches like thoracic endovascular aortic repair (TEVAR) for specific patient populations. The study likely provided data on long-term survival rates, complication rates (stroke, paralysis, etc.), and the overall quality of life post-surgery. However, without access to the full study, specific quantitative results cannot be provided.

Who is a good candidate for total aortic arch replacement (TAR)?

Total arch replacement (TAR) is a complex surgery, and careful patient selection is essential. While the text does not explicitly detail the criteria, suitable candidates are likely those with significant aortic arch aneurysms or dissections where less invasive procedures like thoracic endovascular aortic repair (TEVAR) aren't appropriate. Factors influencing the decision would include the extent and location of the aortic damage, the patient's overall health, age, and any pre-existing conditions. Patients with connective tissue disorders might require TAR, as TEVAR may not provide sufficient long-term support. Discussing individual circumstances with a qualified cardiovascular surgeon is crucial.