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

Abstract

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.

Highlight box.

Surgical highlights

• Direct ascending aorta access via mini-sternotomy for thoracic endovascular aortic repair (TEVAR) is attractive and effective life-saving option in the setting of critical peripheral atherosclerosis.

What is conventional and what is novel/modified?

• TEVAR is usually performed via transfemoral access.

• Introduction of the stentgraft via ascending aorta through mini-sternotomy can be life-saving strategy in the absence of any possible peripheral access.

What is the implication, and what should change now?

• Alternative access for TEVAR should be considered in case of severe peripheral atherosclerosis. One option is access via ascending aorta via partial upper mini-sternotomy.

Introduction

Thoracic endovascular aortic repair (TEVAR) is recommended as the first line of treatment option in patients with descending thoracic aneurysm (1). According to the 2026 European Society for Vascular Surgery (ESVS) Guidelines, patients with descending thoracic aortic aneurysms and an aortic diameter ≥6.0 cm should be considered for repair (1). Adequate vascular access is key to obtain technical success, as guidewires, sheaths and stentgraft system need to be introduced. Standard TEVAR access utilizes the common femoral artery, with retrograde advancement of the system under fluoroscopic guidance. This can be challenged by atherosclerotic occlusive disease, tortuosity, angulation, calcification, or thrombus of the aorto-iliofemoral trajectory (2). Moreover, hostile access may also result from small-caliber vessels, which are more prevalent among females (3). Alternative access includes: transiliac, endoconduits, balloon-expandable sheaths, transaxillary, transcarotid, transapical, transcaval, and direct aortic access methods. The choice of the alternative access depends on the anatomy, device planned to use and region of the aorta to be treated (4). Transaortic TEVAR remains poorly described in the literature. Exposure of an ascending aorta with use of partial sternotomy was described in 2009 by Milner, where a 12 mm conduit was sutured into aorta to enable introduction of a device (5). In 2014, Komlo described direct transaortic approach for both transcatheter aortic valve replacement and descending aortic aneurysm repair via minimally invasive partial sternotomy (6). In 2016, Botta reported two successful cases of the direct aortic approach through right mini-thoracotomy (7). This access was also previously described by Anaya-Ayala, for TEVAR of the aortic arch aneurysm (8). In 2020, Hansen described direct puncture of the ascending aorta via right anterior mini-thoracotomy in the third intercostal space (9). Direct aortic access enables antegrade deployment of a stentgraft into aorta. In case of prohibitive peripheral access, this option proves feasible. Upper mini-sternotomy can be used to obtain ascending aorta entry. This is minimally invasive approach and the treatment goal is curative. We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1199/rc).

Preoperative preparations and requirements

We report a case of a 66-year-old male, 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 (Figure 1). The presumed etiology was degenerative with extensive diffuse atherosclerosis and possible unrecognized previous local dissection. Additionally, extensive diffuse atherosclerosis was visualized (Figure 2). For detailed anatomical measurements, see Table 1. The patient was urgently transferred to a cardiac surgery department. Past history included arterial hypertension and chronic alcohol use. The patient did not receive regular antihypertensive treatment due to lack of compliance. Initially, a minimally invasive endovascular approach was planned. Open surgical repair was discussed as a potential treatment option, however, given the patient’s clinical status, comorbidities, and the emergency setting, an endovascular solution was considered preferable. 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). The iliac perforation was treated with a Cook iliac limb as an emergency bailout rather than with a dedicated peripheral covered stent. The injury occurred in a severely atherosclerotic iliac artery during attempted advancement of a 22-Fr sheath system and was most likely caused by engagement of the dilators or sheath tip with a rigid atherosclerotic plaque. Because the rupture was extensive and associated with brisk extravasation and rapid loss of arterial pressure, immediate endovascular control was required. The Cook iliac limb was selected because it was immediately available in the operating room, compatible with the equipment already in use, and allowed rapid sealing of the arterial tear without procedural delay. Due to severe calcification of the opposite site, immediate conversion was not considered. Only after reassessing the patient was the decision made to try contralateral access. 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. The most probable cause was rupture of the pseudoaneurysm into the bronchial tree or lung parenchyma, i.e., the formation of an aortobronchial fistula. However, an urgent computed tomography (CT) scan was performed right after resuscitation to search for a possible bleeding site or visible fistula, and no bleeding site was found; the scan showed findings suggestive of blood filling the small bronchioles and alveoli. There was no blood found in the lumen of the gastrointestinal tract. Next, an emergency decision was made to access the aorta through an upper mini-sternotomy, as no peripheral access remained available. The team carefully considered alternative access options, including iliac conduit creation, endoconduit techniques, transcaval access, transaxillary/subclavian access, transapical access, and direct abdominal aortic access. Due to the patient’s anatomy, extensive vascular calcification, emergent clinical deterioration, and procedural feasibility considerations, these options were deemed less favorable than direct ascending aortic access, including local cardiac surgery with extensive experience in the upper ministernotomy approach. Device selection was based on anatomical suitability and immediate availability in the emergency setting. The procedure was conducted in a hybrid operating room equipped with fluoroscopy and transesophageal echocardiography (TEE). The room was equipped with endovascular operating C-arm unit (Allura, Philips Medical Systems, Best, The Netherlands). Available image intensifier field sizes were 17, 23 and 31 cm. The procedure was carried out by experienced cardiac surgeons and interventional radiologists. Standard antibiotic prophylaxis was used. Standard urinary catheterization was done. The patient was put under general anesthesia with intubation. The patient received 5,000 IU of heparin. The endocavitary pacing electrode for temporary ventricular pacing was placed percutaneously.

Figure 1.

Aneurysm of the descending aorta, CT reconstruction. CT, computed tomography.

Figure 2.

Severe atherosclerosis of the iliac arteries, CT reconstruction. CT, computed tomography.

Table 1. Minimum luminal diameter of target vessels.

Vessel	Minimum luminal diameter (mm)
Left EIA	9
Right EIA	9
Left CIA	11
Right CIA	12
Left CFA	11
Right CFA	8

CFA, common femoral artery; CIA, common iliac artery; EIA, external iliac artery.

Ethical considerations

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Standard upper J mini-sternotomy to the level of 3^rd intercostal space with lateral extension into the intercostal space was performed. The ascending aorta was visualized. The pericardium was opened partially and attached with 4 sutures to the subcutaneous tissue for better aorta visualization. Purse-string 4-0 sutures with Teflon pledgets were placed in an atherosclerosis-free spot (Figure 3). The left femoral artery was punctured percutaneously by Seldinger’s technique for the introduction of a 6 F straight catheter with side holes on a pigtail 5 F one in the ascending aorta to position the landing zone target. Contrast medium was injected by an automatic syringe. For aorta puncture, the long needle was used, and the puncture point was located percutaneously, 3 cm below the skin incision for mini-sternotomy and aligned coaxially with the ascending aorta. The GORE DrySeal Flex Introducer Sheath size 22 F was used (Figure 4). The stentgraft system was advanced into the thoracic aorta over an Amplatz 0.35 guide wire. A stentgraft (GORE TAG Conformable Thoracic Stent Graft, 40 mm × 40 mm × 150 mm, non-tapered, Newark, DE, USA) was successfully deployed (oversized up to 10%). The oversizing strategy was selected to achieve adequate sealing while minimizing the risk of aortic injury. This was self-expandable stent graft; no balloon molding was used. Finally, to confirm appropriate stent graft position and to exclude any endoleaks, control digital subtraction angiography (DSA) was done. No cerebral protection strategies or specific deairing were done, except proper sheath-flushing maneuvers. In some centers, it is possible to offer cerebral protection. The temporary ventricle pacing was used during the graft deployment and again during sheath externalization. The role of rapid ventricular pacing was to reduce cardiac output, decrease blood pressure, and aortic movement during critical procedural steps, thereby improving deployment accuracy and, in the final step, facilitating safe sheath removal. The “tourniquet-like control” was managed for safe aorta closure. The post stentgraft sheath tunnel was adopted for mediastinum drain placement. The sternum was closed in a typical manner (Video 1). The procedure took 1 h 30 min, fluoroscopy time 3 min 20 sek. Blood loss was estimated to be 250 mL. Activated clotting time (ACT) monitoring was conducted. Protamine was used to reverse the action of heparin. Additional information regarding this procedure is presented in Table 2.

Figure 3.

Purse-string sutures on the ascending aorta as preparation for advancement of the stentgraft system.

Figure 4.

Introduction of the stentgraft system.

Video 1.

Download video file ^{(9.5MB, mp4)}

The video demonstrates antegrade TEVAR via direct ascending aorta access through an upper mini-sternotomy. It shows aortic preparation, delivery system introduction, stentgraft deployment, and closure of the access site. TEVAR, thoracic endovascular aortic repair.

Table 2. Additional information.

Parameter	Value/measurement
Ishimaru zone of the thoracic aortic lesion	LZ4
Proximal neck/landing zone diameter, mm	36
Distal neck/landing zone diameter, mm	30
Distance from the left subclavian artery, mm	56
Distance from the celiac trunk, mm	84
Diameter and quality of the ascending aorta at the puncture site	32 mm, very calcified, spot-free from calcification, 1.5 cm ×1.5 cm
Contrast volume, mL	80
DAP, Gycm2	220
Air kerma, μGym2	7,110
Total, mGy	161

DAP, dose-area product; LZ4, landing zone 4.

Postoperative considerations and tasks

After the procedure, the patient was closely monitored in the intensive care department. The short-term ventilation support was needed. Echocardiography showed good heart function with ejection fraction of 55% and no pericardial fluid. Patient required transfusion of two units of blood. During the entire stay patient was rehabilitated. After 9 days post procedure patient was transferred to referring hospital. Contrast-enhanced CTA scan after 16 days showed no abnormalities (Figure 5).

Figure 5.

Control CT scan. CT, computed tomography.

Tips and pearls

1. Find a proper atherosclerotic free aortic spot close to sinotubular junction (STJ).

2. Place 2 purse-string sutures with pledges.

3. Use short, stiff introducer sheath for stiff wire before the stentgraft sheath—placed percutaneously aligned coaxially with ascending aorta, as shallow as possible in arch (the puncture point below the skin incision for mini-sternotomy).

4. Avoid deep advancement to reduce arch trauma, stroke risk, and wire instability.

5. Use extra-stiff wire (e.g., Lunderquist-type).

6. Remove sheath under controlled hypotension (temporarily)—attractive rapid ventricular pacing (endocavital electrode).

7. Tie pre-placed purse strings immediately—use “tourniquet-like control”.

8. Put drainage drain via skin access puncture point.

Discussion

We demonstrate the feasibility of using ascending aorta via upper mini-sternotomy as access for introducing stentgraft into descending aorta. This method may represent a feasible alternative access option for TEVAR in selected patients with severe peripheral atherosclerosis when conventional access routes are unavailable. The key strength of our report is the proof of feasibility of using direct ascending aorta access via upper mini-sternotomy.

We emphasize that, in such cases, alternative access sites should be considered, including transcarotid approach, iliac conduit creation, endoconduit techniques, transcaval access, transaxillary/subclavian access, transapical access, and direct abdominal aortic access. Based on procedural feasibility considerations, the team deemed these options less favorable than direct ascending aortic access. The transcarotid approach was not considered due to severe calcification in the carotid arteries. Moreover, our cardiac surgery department has extensive experience with the upper mini-sternotomy approach, which is used for the majority of surgical aortic valve replacement and ascending aortic aneurysm procedures. Therefore, while direct ascending aortic access was considered the most appropriate option in our institution, other access strategies may be preferred in centers with different expertise and procedural experience.

The two most commonly described surgical exposures are upper mini-sternotomy and right anterior thoracotomy. Both approaches provide direct access to the ascending aorta for antegrade stent-graft delivery, but differ in exposure, technical ergonomics, and perioperative profile. However, mini-sternotomy is more commonly reported and preferred for predictability and control. Right thoracotomy is used selectively for minimally invasive preference or redo cases. The literature favors mini-sternotomy as the more reproducible and controlled approach, while right thoracotomy remains a valuable alternative in selected redo patients and experienced centers. Crucial limitations for right thoracotomy are: limited exposure of ascending aorta; technically more demanding cannulation angle; reduced ability to rapidly convert to full central access; hemostasis can be more challenging due to lateral orientation; increased difficulty in managing complications (bleeding, rupture). Potential risks of mini-sternotomy approach and direct aortic access include: type A retrograde dissection, embolic stroke, bleeding, aortic injury, mediastinal hematoma, and spinal cord ischemia. However, in this case, the risk-benefit ratio favored immediate intervention.

In addition, the potential risks associated with antegrade deployment and inverted device orientation should be acknowledged, including the theoretical possibility of stent-graft collapse or infolding. In the present case, the procedure was performed under emergency conditions following the patient’s clinical deterioration, which limited the available treatment options. To mitigate these risks, a GORE stent-graft was selected because of its design characteristics, including a relatively balanced radial force distribution at both the proximal and distal ends of the device. In our assessment, these properties may reduce the likelihood of device infolding when the device is used in an inverted configuration. Nevertheless, given the limited evidence for this approach, the safety and durability of this strategy require further evaluation and should be interpreted with caution.

In retrospect, earlier escalation to direct aortic access should be considered a reasonable and potentially preferable strategy in similarly hostile anatomical settings. This case highlights an important learning point: namely, that a timely transition to more definitive access routes may help avoid the risks associated with prolonged attempts at alternative endovascular strategies. In particular, earlier decision-making in favor of direct aortic access may reduce the likelihood of complications related to unstable aneurysm morphology, procedural delay, or further clinical deterioration. These considerations underline the importance of rapid recognition of access limitations and proactive selection of the most secure and definitive approach in complex TEVAR cases.

Moreover, this approach might be particularly useful in patients with smaller-caliber vessels, especially females. Sex-related differences are growing in importance in medicine and should be taken into consideration when planning TEVAR.

Long-term follow-up is necessary to evaluate possible complications. The main limitation of this case is the patient’s short follow-up due to noncompliance. Control contrast-enhanced CTA was performed 16 days post-procedure, while the patient was still in the hospital. After discharge, he did not attend any scheduled visits; however, data from the national health system indicate that he remains insured.

Conclusions

TEVAR with difficult peripheral access remains a challenge. Direct ascending aortic access via partial upper mini-sternotomy may be a feasible bailout option for TEVAR in highly selected emergency cases when conventional and alternative peripheral access routes are unavailable. This approach should be reserved for experienced centers with immediate surgical and endovascular bailout capability. We recommend close collaboration between cardiac and vascular surgeons and interventional radiologists when planning the approach.

Supplementary

The article’s supplementary files as

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this article, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.