Modified sutureless total arch replacement using Gore thoracic stent graftfrozen elephant trunk(FET) technique with VasoRing connector under bilateral antegrade cerebral perfusion: pitfalls and clinical advantages

Acute type A aortic dissection (ATAAD) is a life-threatening emergency despite advances in surgical management. Conventional techniques relying on hand-sewn anastomoses, deep hypothermic circulatory arrest, and unilateral antegrade cerebral perfusion are associated with prolonged operative times and high morbidity. This study aimed to evaluate a modified protocol integrating sutureless anastomosis, frozen elephant trunk (FET), and bilateral antegrade cerebral perfusion (ACP). The data of 17 patients (mean age 56 years; 59% male) who underwent emergent total arch replacement for ATAAD in our center between [2023/11-2025/06] were analyzed retrospectively, incorporating proximal and distal sutureless aortic anastomoses with the VasoRing vascular connector (Sunwei, Taipei, Taiwan), Gore thoracic stent graft FET technique for primary entry tear exclusion and to promote distal aortic remodeling, and bilateral ACP via Fuji catheters under moderate hypothermia. Perioperative data and early outcomes were reviewed. VasoRing vascular connectors were successfully applied in 82% (proximal) and 88% (distal) of cases. Mean cardiopulmonary bypass, myocardial ischemic time, and visceral circulatory arrest time with cerebral perfusion were 293, 172, and 67 min, respectively. Bilateral ACP was achieved in 77% of patients. No 30-day mortality or reoperation for hemorrhage occurred, although one ischemic stroke and two cases of paraplegia were observed. Postoperative imaging demonstrated favorable aortic remodeling, with high rates of false lumen thrombosis or reduction in size across the stented aortic segment. Sutureless total arch replacement with Gore thoracic stent graft FET technique and bilateral ACP appears technically feasible and may provide acceptable early outcomes in ATAAD, offering advantages in operative efficiency and aortic remodeling, although neurologic outcome in acute type A aortic dissection remains a significant concern.