SAAD is the most common cardiac surgical emergency with a high burden of mortality and morbidity. Patients surviving emergency surgery are at an increased risk of ongoing downstream aortic degeneration. There has been a growing consensus that a more extended repair at the initial insult would limit this issue. However, concerns over acute operative outcomes may limit the extent of repair that is considered safe by the surgeon [4].

Distal anastomotic new entry (DANE) is considered to be an important cause of a persistent false lumen following repair of acute aortic dissection [5]. AMDS stent is a novel uncovered aortic arch hybrid graft implanted antegradely during hypothermic circulatory arrest to promote true lumen expansion and enhance aortic remodelling. Developed as an adjunct to standard surgical repair, it aims to improve malperfusion and promote remodelling of the aortic arch and distal dissected aorta at the time of initial surgery without complicating surgery [1].

The use of the AMDS is becoming more common in emergency surgery for acute aortic dissection, with a view to stabilising the true lumen and creating a landing zone for thoracic endovascular aortic repair (TEVAR) options. Use of the AMDS device requires careful pre-operative planning to avoid central AMDS collapse [6].

AMDS stent use is contraindicated in patients with genetic aortopathy and nickel allergies as per the manufacturer: They should be avoided when tears extend into the arch. These cases should be managed by resection of the arch tear or obliteration with a covered stent following debranching procedure due to the risk of an ongoing patent false lumen. Despite promising results, the unknown issues surrounding redo-surgery for the aortic arch as well as a yet to be proven long-term clinical safety and efficacy, total arch replacement remains the best evidence based practice in SAAD involving the arch [7].

Surgical options for total arch repair in cases where an AMDS device has been inserted are somewhat unknown. The device itself cannot be removed, which can cause a significant problem should surgical re-intervention be required, either due to a persistent false lumen or a leak. In this case, a covered endovascular stent was not an option due to the arch vessel patency and as such careful planning and multidisciplinary discussion helped to plan a surgical approach to debranch the arch and stabilise the false lumen. Re-operation with an AMDS in situ can present many technical challenges with the device also noted to distort the anatomy and create difficulty in accessing the arch vessels.

The AMDS device has ultimately shown promising results in studies so far in relation to aortic remodelling. As this case shows however, there are pitfalls to its use, including complicating the approach to further surgery involving the arch. Longer term data is required to clarify whether this arch management strategy improves late remodelling and reduces the need for further reintervention. The technical feasibility of reinterventions in the context of an in situ uncovered stent are also unknown however, we present one possible approach with a good outcome.