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

Area of Science:

• Cardiovascular Surgery
• Thoracic Surgery
• Medical Devices

Background:

• Arch-branched endovascular repair (B-TEVAR) is an emerging alternative to open arch repair for high-risk patients.
• Increasing use of B-TEVAR will lead to more complex reoperations involving the ascending aorta (AA) and heart valves.
• No established techniques exist for open AA repair following B-TEVAR.

Purpose of the Study:

• To describe surgical techniques for open ascending aorta (AA) and valve repair in patients with prior B-TEVAR.
• To provide technical insights for managing complex reoperations after B-TEVAR.

Main Methods:

• Two patients with prior B-TEVAR underwent open AA and valve surgery.
• Techniques included circulatory arrest with selective bicarotid perfusion and femoral-femoral bypass with distal aortic control and selective brachiocephalic trunk (BCT) perfusion.
• Detailed surgical planning considering endograft position and branch orientation was crucial.

Main Results:

• Both complex reoperations were technically successful.
• One patient recovered uneventfully; the other had a prolonged ICU stay but a full recovery.
• Preoperative CT with 3D reconstruction was essential for surgical planning.

Conclusions:

• Ascending aorta (AA) and valve repair after B-TEVAR is feasible.
• These cases offer valuable insights for managing challenging reoperations as B-TEVAR adoption grows.
• Tailored surgical approaches are mandatory, focusing on endograft branch position and direction.