The Aortic Crossroad: Midterm Follow-up Results After Antegrade Thoracic Endovascular Aortic Repair via Right Anterior Thoracotomy After Frozen Elephant Trunk

Background: The common femoral artery is the standard access route for thoracic endovascular aortic repair (TEVAR). However, it is still a significant issue in a patient population who often has many comorbidities including peripheral arterial disease, so that alternative routes must be considered.

Methods: Between January 2021 and December 2023, five patients with history of total aortic arch replacement using frozen elephant trunk underwent nine TEVAR procedures. Among them, there were three male patients, mean age 62, who underwent antegrade stent-graft deployment using the ascending aortic prosthetic graft as access route. The procedure was performed particularly for degenerative aneurysms of the descending aorta, three patients for aneurysm of descending thoracic aorta and two patients for penetrating aortic ulcer. All patients included in this series had an American Society of Anesthesiology score of 4 or greater. The peripheral artery disease with iliofemoral involvement hampered endovascular access to the site from the common femoral artery. We chose to access the ascending aorta prosthetic graft with a thoracotomy from the right third intercostal space for TEVAR.

Results: The 30-day postoperative mortality was 0%. No endoleaks were observed postoperatively and in median midterm follow-up period of 36 months using contrast-enhanced computed tomography (CT). There were no major cardiac adverse events related to the stent-graft implantation in the follow-up period.

Conclusion: Our follow-up data suggest that antegrade TEVAR can be performed safely by using the prosthetic ascending aortic graft through a right anterior thoracotomy as access route, if variations of vascular anatomy or peripheral artery disease interfere with the more commonly used femoral artery approach. Longer term follow-up is needed to determine the durability of thoracic endovascular aortic repair in this setting.

Publication History

Article published online:
11 February 2025