Endovascular Solution for Anastomotic Pseudoaneurysm of the Ascending Aorta

The objective was to demonstrate the feasibility of ascending thoracic endovascular aortic repair (a-TEVAR) as a minimally invasive treatment for an ascending anastomotic pseudoaneurysm in a patient unsuitable for redo open surgery.

The steps included: 1) multidisciplinary evaluation and detailed computed tomography angiography-based anatomical planning; 2) assessment of proximal and distal landing zones, coronary ostia, and supra-aortic vessel anatomy; 3) selection of a Gore C-TAG endograft based on anatomical suitability; 4) percutaneous transfemoral a-TEVAR under rapid ventricular pacing with intraoperative angiographic guidance; and 5) confirmation of complete pseudoaneurysm exclusion while preserving coronary and supra-aortic vessel patency, followed by serial computed tomography angiography surveillance.

Limited landing zones, proximity to the coronary ostia and supra-aortic vessels, inaccurate device deployment, and the absence of dedicated ascending aortic devices increase procedural complexity. Careful patient selection, meticulous preoperative planning, and rapid ventricular pacing are essential to minimize these risks.

The a-TEVAR procedure is a feasible alternative to high-risk redo sternotomy in carefully selected patients with favorable anatomy. However, a-TEVAR of the ascending aorta continues to pose significant technical and clinical challenges, and further investigations are needed.