Recurrent laryngeal nerve injury
Proponents of zone 0 aortic arch repair argue that the proximalisation of the surgical field not only improves the surgeon’s access to the sites of anastomosis but also decreases risk of damaging the recurrent laryngeal nerve (RLN), which loops under the aortic arch in close proximity to zones 2 and 3.18, 29 Indeed, Leoneet al. concluded that proximalisation of arch repair from zone 3 to zone 2 reduces the risk of RLN injury from 11% to 2.8%, while Jakob and colleagues argue that Z-2-FET effectively eliminates this risk.18, 23 It is therefore unsurprising that following Z-0-FET, Yamamoto et al. reported only a single incidence of vocal cord paralysis resulting from RLN injury.16 In contrast, Beckmann noted a 18% (n=17) incidence of RLN palsy following Z-2-FET.12 Indeed, reduced incidence of RLN palsy may well represent surgical advancement with FET proximalisation.