Arch-First Technique for Extensive Thoracic Aortic Replacement: A Case Series of Patients With Complex Thoracic Aortic Disease.

BACKGROUND Given its associations with high morbidity and mortality, type A aortic dissection requires urgent surgical intervention. Patients with Marfan syndrome present additional complexity due to underlying connective tissue abnormalities that warrant multiple thoracic aortic operations. The "arch-first" technique was developed to allow single-stage open extensive replacement of the thoracic aorta while maintaining continuous antegrade cerebral perfusion, thereby minimizing brain ischemia. In the current endovascular era, the frozen elephant trunk - a hybrid technique combining a conventional surgical graft for arch reconstruction with an integrated distal stent-graft - has gained popularity in management of these cases, displacing extensive open approaches. However, for specific patient populations, the arch-first technique remains a suitable approach. CASE REPORT This report describes 6 patients (5 men, 1 woman; aged 24-73 years) who were treated between June 2022 and June 2025 through application of the arch-first technique in complex clinical scenarios, highlighting its benefit in providing effective single-stage management of extensive thoracic aortic pathology. Although no patient experienced neurological deficits, 50% (3/6) required prolonged mechanical ventilation due to the invasiveness of the procedure. CONCLUSIONS The arch-first technique represents an effective surgical strategy for single-stage extensive thoracic aortic replacement, offering reliable cerebral protection and reduced neurological risk in complex aortic disease cases, particularly those involving patients with Marfan syndrome and in reoperation settings. Despite its invasive nature and potential for pulmonary morbidity, the arch-first technique remains a valuable option for selected patients. Further multicenter studies are needed to compare its outcomes with frozen elephant trunk and hybrid approaches.