The standard repair for ATAAD involves resection of the primary tear and closure of the FL at the distal anastomosis. This manuscript explores cases where AMDS fails to close the FL, either due to a new entry at the distal anastomosis postoperatively or initial difficulties in resecting the distal tear, both contributing to persistent FL perfusion and malperfusion management failure [4].

Compared to hemiarch replacement with AMDS, the TAR with FET technique offers the advantage of placing a stent-graft into the TL of the distal arch, sealing re-entry tears in both the aortic arch and proximal descending thoracic aorta in a single-stage procedure, as demonstrated in case (1) Along with the Z-shape stent design of the E-Vita Open Neo Trifurcated prosthesis could reduce the risk of dSINE as it exerts less focal stress to the aortic wall. Additionally, it creates a covered landing zone for a second-stage TEVAR in case of persistent FL perfusion, as shown in case (2) However, this approach can increase the time of both cardio-pulmonary bypass and circulatory arrest increasing the risk of stroke or haemorrhage [5] .

The DARTS trial [1] reported successful AMDS implantation in 46 patients, with a 3-year follow-up revealing an increase in the aortic diameter in zones 1 and 2 in 27.3% and 25% of patients, respectively. Additionally, a patent FL was observed in 40% of patients in zone 1 and 31.8% in zone 2. Six patients (13%) required disease-related reinterventions; however, no reinterventions on the aortic arch were necessary.

Montagner et al. [6] observed that the low radial force of the AMDS stent is primarily designed to realign the intimal layer against the media and adventitia. The ultimate resolution of malperfusion relies on the successive expansion of the TL. In acute aortic dissection, the intimal flap remains highly mobile, allowing the distal end of the stent to expand fully, positioning the dissection flap adjacent to the outer aortic wall [7]. However, the emergence of new entry tears may keep the FL patent, causing further expansion of the FL at the expense of the low radial force of the AMDS, as evidenced in both cases.

The AMDS lacks sufficient radial force to reliably ensure the distal expansion of the TL, especially in cases of visceral malperfusion, as reported by Kanj et al. [8]. Importantly, this limited radial force should not prompt surgeons to oversize the stent, as this could result in stent collapse due to the higher radial force exerted by the aortic arch. Moreover, excessive radial force on the aortic arch wall may result in dSINE, as shown in case 1.

The radial force of endovascular stents plays a critical role in supporting blood vessels, maintaining lumen patency, and ensuring secure fixation to the arterial wall [9]. Radial force varies between stent designs, influenced by factors such as stent type, deployment site, and the specific characteristics of each stent layer [10]. Given this variability, oversizing the AMDS should be avoided, and adherence to manufacturer-recommended sizes is strongly advised.

While the AMDS has potential, its ability to promote positive aortic remodelling remains uncertain and appears less likely when compared to the FET technique. The primary issue seems to lie in the AMDS’s insufficient radial force, which tends to elongate rather than expand, limiting its effectiveness in this regard [8].

Another notable characteristic of the AMDS is that it is an uncovered stent. The main limitation of bare stents is their inability to seal entry tears, unlike covered grafts that can immediately close tears while preserving the patency of the vessel. In this scenario, any entry tear not sealed by the bare stent will remain active. Therefore, the use of AMDS should be reserved for type A aortic dissections where the primary tear is located in the root or ascending aorta, ensuring the aortic arch is free of any additional tears for optimal results.

In the rare instances where aortic arch reintervention is necessary in zones covered by AMDS, significant challenges arise due to the potential ingrowth of the stent into the aortic wall. Removal of the stent poses a high risk of damaging the aortic wall, potentially causing rupture. Cutting the AMDS can lead to stent unwinding, increasing the risk of late stent migration and associated mortality. An alternative approach, such as aortic arch debranching followed by endovascular stent grafting, could be considered, however, the recoil properties of AMDS complicate efforts to seal the aorta using endovascular solutions.

The outlined strategy facilitates the repair by keeping the AMDS in place, allowing the FET technique in aortic zone 0 or 1 with debranching of head vessels. Moreover, it provides a secure landing zone for TEVAR in cases of persistent FL perfusion.