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

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.

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.

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.

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 ImpactArch-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.