In surgery for acute type A aortic dissection (ATAAD), both the proximal and distal anastomoses are crucial because secure sealing and hemostasis are essential to prevent bleeding and ensure a durable repair. Although the proximal anastomosis is considered the most technically demanding step due to the complex anatomy of the aortic root, the distal anastomosis significantly influences the extent of aortic replacement and overall surgical complexity. Its technical difficulty and risk vary depending on whether the procedure involves ascending aortic replacement, hemi- arch replacement, or total aortic arch replacement. Moreover, failure at the distal anastomosis—particularly in the form of a distal anastomotic new entry (DANE)—can result in persistent false lumen (FL) perfusion, thereby increasing the risk of complications in the aortic arch or descending thoracic aorta [1].

Tear-oriented surgery remains a key principle in ATAAD management, with many cases treated using ascending aortic or hemi-arch replacement. While these approaches can be life-saving, they may not adequately prevent long-term complications or reduce the need for reintervention. A DANE functions similarly to a primary entry tear by allowing antegrade pulsatile flow into the FL and maintaining its patency. Studies have identified DANE in more than 70% of standard hemi-arch repairs, contributing to high rates of negative remodeling and accelerated aortic growth. Additionally, distal re-entry tears affect FL pressurization, and when FL inflow exceeds true lumen (TL) flow, negative remodeling and late complications become more likely [2,3].

Given these concerns, optimal management of persistent FL requires careful consideration. In recent years, total aortic replacement (TAR) with or without frozen elephant trunk (FET) has gained recognition, and there is a growing trend toward more aggressive implementation to improve long-term outcomes [2,3]. However, the risks associated with extended arch procedures, as well as the influence of surgical expertise, must be weighed when determining the optimal approach.

In this issue of the journal, Furui et al. [4] introduced a procedure aimed at preventing DANE and potentially avoiding TAR in high-risk patients. This technique involves injecting BioGlue into the FL and adhering the dissecting membrane to the outer aortic wall from the distal anastomosis site to the transverse arch, using an aortic balloon. Ten patients with ATAAD underwent this procedure, and postoperative day 7 computed tomography scans showed no evidence of DANE and confirmed thrombosis within the FL of the transverse aortic arch. Although the results are promising, several key factors must be addressed to enhance the clinical applicability of this procedure.

First, there is the issue of BioGlue application at the distal anastomosis. While BioGlue appears promising for optimizing hemostasis, reducing operative time and blood loss, and minimizing hypothermic arrest in ATAAD surgery, it raises significant safety concerns, including glutaraldehyde-related tissue toxicity and embolization. Complications related to tissue toxicity, such as pseudoaneurysm formation, were reported in the 2000s [5]. Carrel et al. [6] proposed 3 potential mechanisms of embolization: (1) direct leakage of glue into the TL, (2) migration through distal re-entry sites, and (3) secondary displacement of glue particles through suture-line needle holes. Given these concerns, the use of BioGlue for FL obliteration in distal anastomosis reinforcement remains debated, particularly regarding its potential to increase embolization risk [7]. However, in 2017, Ma et al. [8] reported a very low incidence of anastomotic pseudoaneurysm formation with BioGlue in thoracic aortic surgery, suggesting that its use should not be discouraged in patients with ATAAD or extreme tissue fragility. Moreover, technical refinements over the past 2 decades have reduced the risk of embolism. Applying a minimal, uniform 1-mm layer of BioGlue within the FL may enhance adhesion while preventing direct leakage and migration. Incorporating techniques such as the turn-up technique used by the authors or additional inner wall reinforcement may optimize BioGlue use in addressing DANE while minimizing the embolic risk from needle hole bleeding in the inner wall.

Second, it is necessary to discuss the procedure for obliterating the FL in the aortic arch using BioGlue. During ATAAD surgery, when systemic perfusion is resumed through a side branch, blood can flow into the FL through distal entry tears, leading to retrograde flow toward the distal anastomosis. If FL pressure rises sufficiently, the sealed area may reopen and BioGlue particles could dislodge. Therefore, this procedure should be avoided if even a small intimal tear is present in the aortic arch, given the potential risk of embolization. In the case presented in the supplementary figure, this procedure was performed on a patient with an intimal tear in the arch; however, this should be considered an exceptional case.

Third, it is important to note that the primary purpose of TL ballooning is not only to approximate the dissecting membrane to the outer wall but also to prevent BioGlue from migrating into the descending thoracic aorta [9]. The authors mentioned that this procedure could be useful for FL obliteration in the descending thoracic aorta as an alternative to using FET during TAR. However, the risk of systemic embolization necessitates careful reconsideration of this concept. The location and size of the re-entry tear are crucial in determining the optimal position for aortic ballooning. Additionally, this technique applies pressure only to the inner wall using a balloon, rather than exerting external pressure on both layers after glue injection. Consequently, even with ballooning, glue injected into the descending thoracic aorta may still migrate distally.

In conclusion, although the authors suggest that the balloon and glue technique can reduce the surgical extent in patients who might otherwise require TAR, this claim is difficult to fully endorse. Based on the principles of tear-oriented surgery, this procedure may be useful in patients selected for ascending aortic or hemi-arch replacement, by preventing DANE and promoting favorable arch remodeling. To further clarify its clinical significance, future studies should evaluate long-term outcomes based on the presence, location, and size of re-entry tears in the descending thoracic aorta.

Author contributions

All the work was done by Sang-Ho Cho.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.