"Head First" approach streamlines aortic arch replacement.

Objective: The "Head First" graft technique has emerged as a preferred approach for aortic replacement by many surgeons. This study evaluated its performance and safety, focusing on operative efficiency, cerebral protection, and its role in open arch repair outcomes. Methods: We reviewed 150 patients who underwent zone 2 or more extensive arch replacement using the "Head First" approach from August 2020 to March 2025. Perioperative variables were compared between patients with acute type A aortic dissection (n = 40) and elective repair (n = 84). Logistic regression identified risk factors for stroke. Results: Patients' median age was 62 [49-69] years, and 64.7% were male. A total of 44% cases were urgent/emergent; 46.7% of patients underwent redo sternotomy, and 77.3% of patients received the frozen elephant trunk procedure. Nadir temperature was 27.4 °C [26 °C-28 °C]. Overall disabling stroke and 30-day mortality were 10.7% and 16.7%, respectively. Compared with elective patients, patients with acute type A aortic dissection had longer bypass (223.5 vs 156 minutes, Conclusions: The "Head First" approach demonstrated acceptable outcomes in complex arch replacement. It prioritizes cerebral protection, facilitates timely reconstruction with shorter circulatory arrest, and may improve technical feasibility.