“Once China awakens, it will shake the world.” Napoleon made this prediction more than two centuries ago, and it has now become a tangible reality. Historically, scientific contributions emerging from China were often regarded with skepticism in Western countries, perceived as potentially biased representations shaped by political interests. Numerous published recommendations warned that findings from Chinese institutions might be unreliable.
The situation, however, has changed dramatically. China has undergone rapid modernization across multiple sectors. In fields such as the automotive industry, their products increasingly dominate global markets, combining not only volume but high quality standards. Chinese cardiovascular surgical research frequently reports patient cohorts of a size rarely attainable in Western centers, including in the United States. Despite comparable disease incidence, the enormous population and a rapidly expanding healthcare system with newly built facilities enable the accumulation of large study populations over short time frames. Additionally, the healthcare network has grown mostly free from traditional structural limitations that affect Western hospitals, many of which carry outdated facilities, insufficient digitization, and error-prone data collection systems.
The study under discussion aims to assess a modification of the traditional end-to-end aortic anastomosis, particularly advantageous during circulatory arrest. This sutureless concept reinforces the aortic wall externally by applying two tied tapes around the vessel, while a graft with a stent sized to match the aortic diameter is positioned intraluminally to achieve a hemostatic seal. The approach reflects an elegant blend of technical rigor, innovation, and surgical tradition that is characteristic of leading Eastern cardiac centers. It is a well-designed investigation that not only reports institutional experience but also provides a propensity-matched comparison with the conventional sutured technique.
Although it may appear to represent a modern, disruptive concept, the authors essentially revisit a historical idea. Hufnagel, during the early experimental era of cardiac surgery, implanted the first mechanical valve using a ball-cage prototype positioned in the descending aorta to treat aortic regurgitation. At that time, prosthetic technology such as the Starr-Edwards valve had not yet been developed. The procedure involved placing the device through a thoracic approach similar to that used for coarctation repair. The device excluded a segment of descending aorta between vascular clamps and was fixed in place using circumferential tapes tied externally, proximally and distally.
Between 2019 and 2023, a total of 382 patients with acute type A aortic dissection underwent complete aortic arch replacement at the authors’ institution. Among them, 86 received the sutureless technique. Following propensity score matching, 77 patients were included in each study arm to perform a balanced comparison.
The unadjusted perioperative outcomes were excellent in both cohorts. Circulatory arrest times were markedly shorter with the sutureless approach, averaging 11 minutes compared with 40 minutes using the conventional technique. Cardiopulmonary bypass duration was also substantially reduced, with averages of 169 versus 243 minutes. After matching, these improvements persisted and were accompanied by lower bleeding burden and decreased transfusion requirements with the sutureless repair.
Importantly, these intraoperative and perfusion-related advantages translated into a significantly reduced perioperative mortality. In the unmatched population, mortality was 9.3% vs 22%. After matching, the difference remained evident (7.8% vs 20.8%). In addition, a 15-month follow-up demonstrated similar survival and reintervention rates among patients discharged alive, confirming the short-term stability of the anastomotic construct.
The authors therefore conclude that their technique enhances perioperative safety in a disease where operative risk remains notoriously high, despite major advances over recent decades.
COMMENTARY:
The technique described by the authors can be conceptualized through a sequence of procedural steps that are straightforward to follow. Cardiopulmonary bypass is established using standard cannulation for unilateral cerebral perfusion via the right axillary artery. Once the supra-aortic branches are controlled, the dissection is clamped to allow proximal repair during cooling. The ascending aorta is transected at least 3 cm above the coronary ostia, preserving the sinotubular junction, which serves as the anchoring zone for the first stent-supported conduit.
The diameter of the sinotubular junction is measured with a Hegar dilator, and a 2.5-cm wide titanium mesh ring is shaped accordingly. This structure is positioned inside one end of a four-branched graft and cemented to the system by external tapes tied around the native aorta. Once target hypothermia is achieved, the clamp is released and the supra-aortic trunks are divided proximally to proceed with the distal anastomotic portion.
The distal repair incorporates a frozen elephant trunk stent-graft with minimal Dacron length. A second titanium ring is sized to be 1–2 mm smaller than the stent diameter. It is inserted into the proximal end of the stent-graft through the distal end of the branched prosthesis. Once again, external tapes are placed circumferentially to achieve a sealed interface. Reimplantation of the supra-aortic trunks is performed using conventional suturing, followed by closure of the native aortic remnant around the prosthesis to complete the reconstruction.
Even with a meticulous written description and illustrative diagrams, intraoperative videos provided by the group are especially striking, showing the apparent integrity of the sealing mechanism without sutures. Furthermore, the postoperative computed tomography assessments offered as dynamic imaging material confirm the absence of early pseudoaneurysm formation, reinforcing the immediate durability of the construct.
This work represents an impressive display of technical innovation that warrants cautious optimism while awaiting more extensive long-term evaluation. Similar to other adjunctive devices such as AMDS, anatomical suitability remains a key determinant of applicability. This is already reflected in the fact that only 22% of eligible patients were ultimately selected for the technique in the global cohort. Although the authors do not detail dissection morphology in depth, the strategy appears most appropriate for cases with a primary entry tear located in the arch, unlike other devices with more restricted indications. A broader and indiscriminate expansion of arch reconstruction in patients whose entry tear resides solely in the ascending aorta would raise concerns regarding the proportionality of the surgical aggressiveness, even if local results remain favorable.
The experience presented should encourage the surgical community to explore new ways of simplifying complex aortic procedures. Industry innovation may eventually incorporate dedicated stent-mounted anastomotic systems designed specifically for sutureless arch replacement, potentially enhancing reproducibility and adoption. Of interest, commercial devices enabling simplified reimplantation of supra-aortic vessels, such as the Rapid Link system (Terumo®), could conceivably be paired with this strategy to render the procedure even more completely sutureless.
For the time being, these developments remain in evolution. The foundational principle of surgical prudence persists as a reminder: avoid being the first to embrace an emerging technique… but also avoid being the last to abandon one that has become obsolete.
REFERENCE:
Qiu DY, Zhu EJ, Li YT, Xue YH, Zhang HT, Sun B, Chi C, Meng WX, Zhang GF, Xu L, Pan HD, Wang H, Pan T, Xie BD. Sutureless total arch replacement in patients with acute type A aortic dissection. JTCVS Tech. 2025;33:1-12.
