Technical Notes: Open Ascending Aorta and Valve Repair Following Total Arch Endovascular Repair

Abstract

Introduction:

Arch-branched endovascular repair (B-TEVAR) is an emerging alternative to open arch repair in high-risk patients. As its use grows, complex reoperations involving the ascending aorta (AA) and heart valves will become more frequent. No prior technique for open AA repair after B-TEVAR has been described.

Technique:

Two patients with prior B-TEVAR underwent open AA and valve surgery. The first patient had AA replacement under circulatory arrest and selective bicarotid perfusion. The second underwent Bentall and mitral valve replacement using femoral–femoral bypass, with a compliant balloon for distal aortic control and selective brachiocephalic trunk (BCT) perfusion.

Results and Discussion:

Both surgeries were successful. The first patient recovered uneventfully. The second had a prolonged ICU stay but recovered fully. Surgical planning must account for endograft position, branch orientation, and clamping strategy. Preoperative CT with 3D reconstruction is essential.

Conclusion:

AA and valve repair after B-TEVAR is feasible. These cases offer technical insights for managing such complex reoperations as B-TEVAR becomes more common.

Clinical Impact

Arch-branched endovascular repair (B-TEVAR) is a less invasive alternative to standard open arch repair (OAR). We describe 2 surgical techniques to successfully perform cardiac surgery, including AA and aortic and mitral valve repairs, in patients with a history of B-TEVAR. Tailored approaches to address these challenging cases are mandatory, with a special focus on the endograft branches position and direction.