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OBJECTIVE: Thoracic endovascular aortic repair (TEVAR) of ascending aortic pathology is feasible, however, the unique features of this aortic segment in addition to access challenges restricts its use to a high-risk subset of patients. We describe transcarotid and transapical vascular access for the endovascular management of acute ascending aortic pathology.
METHODS: Five patients with acute ascending aortic pathology at extreme risk for conventional surgery were managed with endovascular stent grafts using either transcarotid or transapical vascular access. Transapical ascending aortic TEVAR used a similar technique to transapical TAVR and both modified and unmodified thoracic stents were utilized. During transcarotid access, surgical technique included delivery of abdominal aortic cuffs through direct exposure of the left common carotid artery with and without a conduit; modification/shortening of the delivery sheath; and intraoperative EEG to guide the need for femoral to carotid shunting during device delivery. In addition to demographics, endpoints in this retrospective review included operative details, procedural complications and follow up.
RESULTS: Pathology included four patients with penetrating ascending aortic ulcers and one patient with a pseudoaneurysm in a previously grafted ascending aorta. Average age was 86 years (range 81-92). Vascular access was transapical (n=3) and left transcarotid (n=2); concomitant procedures included transapical TAVR for associated aortic stenosis (n=1) and transfemoral TEVAR for descending dissection/aneurysm (n=1). Procedural success was 100% without deaths or strokes. No transcarotid patient required femoral to carotid shunting. Median length of stay was 4 days (range 3-8); All patients were discharged to home. With a median follow up of 12 months (range 2-20 months) survival remains 100% with no late carotid access complications and stable endografts without endoleaks by computed tomography.

CONCLUSIONS: Endovascular management of ascending aortic pathology is feasible using both transapical and transcarotid vascular access. To our knowledge, these are the first reported cases using transcarotid access in the successful endovascular management of ascending aortic pathology.