Use of Transapical Access for Thoracic Endovascular Aortic Repair in Challenging Aortic Anatomy: A Case Report

Few cases have reported the use of a transapical approach for thoracic endovascular aortic repair (TEVAR) when standard retrograde device delivery is not feasible. We present the unique case of a 74-year-old female with a history of descending thoracic TEVAR, a physician-modified fenestrated endograft, and ascending aortic repair who presented with an enlarging aortic arch aneurysm requiring intervention. Her native aorta was notably tortuous, and a patient-centered decision was made to proceed with transapical access via a mini-thoracotomy after unsuccessful retrograde endovascular attempts due to severe tortuosity and prior endografts. The stent graft was successfully deployed without type I or III endoleak. The patient recovered without neurologic deficits and was discharged on postoperative day 7. This case highlights transapical access as a feasible alternative route for TEVAR in selected patients with prohibitive anatomy and underscores the importance of multidisciplinary collaboration and timely management of proximal aortic pathology.