Mini-sternotomy as a life-saving access for thoracic endovascular aortic repair in the absence of peripheral options

Managing descending thoracic aortic disease with thoracic endovascular aortic repair (TEVAR) in patients with extensive peripheral atherosclerosis remains highly challenging. A 66-year-old male was admitted to a district hospital with symptoms of upper respiratory tract infection, where emergency imaging [X-ray, followed by contrast-enhanced computed tomography angiography (CTA)] incidentally revealed a descending thoracic aorta pseudoaneurysm and diffuse atherosclerosis. The patient was urgently transferred to a cardiac surgery department. Past history included arterial hypertension, chronic alcohol use, and absence of long-term therapy. Initially, a minimally invasive endovascular approach was planned. The first attempt to implant a stentgraft via the left external iliac artery was complicated by vessel perforation, requiring stentgraft implantation (Cook ZISL 13 mm × 56 mm, Bloomington, IN, USA). On the following day, right iliac access was attempted with the support of intravascular lithotripsy (Shockwave Javelin Peripheral IVL Catheter, 7 mm, Santa Clara, CA, USA), but severe calcifications prevented advancement of the delivery system. On the third day, the patient's condition deteriorated rapidly, presenting with hemoptysis, followed by cardiac arrest. After resuscitation, an emergency decision was made to access the aorta through an upper mini-sternotomy, as no peripheral access remained available. A stentgraft (GORE TAG Conformable Thoracic Stent Graft, 40 mm × 40 mm × 150 mm, non-tapered, Newark, DE, USA) was successfully deployed. The procedure was completed without intraoperative complications. Postoperative contrast-enhanced CTA confirmed correct stentgraft positioning without endoleaks. The patient required short-term mechanical ventilation and inotropic support, but recovery was uneventful. A follow-up computed tomography (CT) performed 16 days later demonstrated no abnormalities. This case highlights the feasibility of ascending aorta access via mini-sternotomy for TEVAR in the setting of critical peripheral atherosclerosis. However, such interventions demand advanced expertise and close collaboration between cardiac and vascular surgeons and interventional radiologists.