Surgical Management of Ascending Aortic and Innominate Artery Pathology Following Previous Aortic Valve Replacement: A Redo Sternotomy Case Report

Suchitran M et al | DOI: 10.65188/nurexus.1063

Page 19

Journal of MedVerse Research & Practice

ISSN: 3107-4278

Surgical Management of Ascending Aortic and Innominate Artery

Pathology Following Previous Aortic Valve Replacement: A Redo

Sternotomy Case Report

Dr. M Suchitran, Dr. V Hemavarthini

Professor, Professor

Department of Cardiothoracic and Vascular Surgery

Vydehi Institute of Medical Sciences and Research Centre, Bengaluru.

Email ID: suchitranm@gmail.com

Submission Date: 22.12.2025

Accepted Date:21.01.2026

Published Date: 31.01.2026

DOI: 10.65188/nurexus.1063

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted

use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Background: Progressive dilation of the ascending aorta after aortic valve replacement (AVR) is increasingly

recognized and may coexist with aneurysms of supra-aortic vessels such as the innominate artery. Concomitant

pathology in the ascending aorta and innominate artery presents complex technical challenges, particularly in a redo

sternotomy setting.

Case presentation: We describe a 30-year-old male with prior mechanical AVR who was incidentally found on

routine imaging to have a dilated ascending aorta with a saccular aneurysm of the innominate artery. After

multidisciplinary evaluation, he underwent elective redo median sternotomy with ascending aorta and hemiarch

replacement and re-implantation/reconstruction of the innominate artery. Cerebral protection strategies and

meticulous surgical technique were used. The postoperative course was uneventful; the patient was extubated on day

1, ambulated on day 2 and discharged in stable condition with preserved neurological function.

Conclusion: With careful preoperative planning, cerebral protection, and experienced surgical execution, redo

sternotomy with hemiarch replacement and innominate artery reconstruction can be carried out safely in selected

patients. Vigilant imaging surveillance after AVR permits elective intervention prior to emergent complications.

Keywords: Ascending aortic aneurysm, Innominate artery aneurysm, Redo sternotomy, Hemiarch replacement,

Cerebral protection, Aortic valve replacement

Introduction

Ascending aortic aneurysm represents a significant cause of morbidity and mortality due to the risk of

rupture, dissection, and thromboembolic complications. Progressive dilation of the ascending aorta

following aortic valve replacement (AVR) is a well-documented phenomenon, particularly in younger

patients with bicuspid aortic valve disease, connective tissue disorders, or longstanding systemic

hypertension [1]. Altered hemodynamic flow patterns, intrinsic medial degeneration, and persistent

aortopathy contribute to progressive aortic enlargement even after correction of valvular pathology [2].

Innominate artery aneurysms are rare and account for less than 3% of all supra-aortic trunk aneurysms [3].

These aneurysms are often asymptomatic and detected incidentally during imaging performed for unrelated

indications. However, they carry substantial risks, including rupture, distal embolization, and compression

of adjacent mediastinal structures [4]. When present in association with ascending aortic aneurysms, they

significantly complicate surgical management.

Suchitran M et al | DOI: 10.65188/nurexus.1063

Page 20

Redo sternotomy for aortic and arch surgery is technically demanding and associated with increased

operative risk due to dense mediastinal adhesions, distorted anatomy, and the potential for catastrophic

hemorrhage during sternal re-entry [5]. Surgical strategies must therefore balance complete pathological

correction with minimization of operative time, cerebral ischemia, and bleeding risk. Hemiarch replacement

with selective re-implantation of supra-aortic vessels has emerged as an effective approach for localized

arch pathology, allowing adequate disease control while avoiding the complexity of total arch replacement

[6]. We present a detailed case of a young adult with post-AVR ascending aortic aneurysm and concomitant

innominate artery aneurysm successfully managed with redo sternotomy, ascending aorta and hemiarch

replacement, and innominate artery reconstruction.

Case presentation

A 30-year-old male presented for routine cardiology follow-up. He had a history of mechanical aortic valve

replacement performed in 2011 for severe aortic valve disease. The postoperative course following AVR

had been uneventful, and the patient was on long-term oral anticoagulation and antihypertensive therapy.

He had a known history of systemic hypertension but no documented connective tissue disorder. There was

no family history of aortic disease or sudden cardiac death.

At presentation, the patient was asymptomatic. He denied chest pain, dyspnea, palpitations, syncope,

neurological deficits, or constitutional symptoms. Physical examination revealed a well-healed median

sternotomy scar. Cardiovascular examination demonstrated normal prosthetic valve sounds with no

murmurs. Peripheral pulses were palpable and symmetrical, and there were no signs of heart failure or

neurological compromise. Routine transthoracic echocardiography revealed normal functioning of the

mechanical aortic valve prosthesis with preserved left ventricular systolic function. However, significant

dilation of the ascending aorta was noted. Given these findings, contrast-enhanced computed tomography

angiography of the thorax was performed for further evaluation.

Computed tomography angiography demonstrated a markedly dilated ascending aorta extending up to the

proximal aortic arch. In addition, a saccular aneurysm involving the innominate artery was identified. The

aneurysm showed no evidence of rupture or thrombosis. The remaining supra-aortic vessels appeared

normal. Based on imaging findings, a diagnosis of ascending aortic aneurysm with concomitant innominate

artery aneurysm in a post – aortic valve replacement patient was established. Given the patient’s young age,

aneurysm morphology, and the risk of future complications, elective surgical intervention was planned. A

multidisciplinary heart team discussion was conducted, and the patient was counseled regarding the risks

and benefits of redoing aortic surgery. Written informed consent was obtained.

Surgical Management

The patient was brought to the operating room and placed under general anesthesia. Standard

neuromonitoring, including near-infrared spectroscopy (NIRS) for cerebral oximetry, was instituted. Redo

median sternotomy was performed with an oscillating saw and careful dissection of the mediastinum to

minimize injury to adherent structures. Dense adhesions were taken down under direct vision. A central

cannulation strategy was planned with readiness for peripheral cannulation if required to secure

cardiopulmonary bypass (CPB) rapidly.

Cardiopulmonary bypass was established and systemic cooling to moderate hypothermia was performed

per institutional protocol. After cross-clamping and cardioplegic arrest (to allow inspection of the valve

prosthesis and ascending aorta), the ascending aorta was opened and the aneurysmal segment was resected.

Hemiarch replacement (proximal arch prosthetic graft anastomosed to the healthy arch) was performed to

Suchitran M et al | DOI: 10.65188/nurexus.1063

Page 21

address proximal arch involvement. Cerebral protection was achieved with selective antegrade cerebral

perfusion via cannulation of the right axillary/inominate/arch vessels based on intraoperative anatomy;

NIRS monitoring helped tailor perfusion pressures and flow.

The innominate artery aneurysm was carefully dissected; a segmental resection of the aneurysmal

innominate trunk was performed and the artery re-implanted into the neo-ascending aortic graft using end-

to-side anastomosis with meticulous suturing. The mechanical aortic valve prosthesis was inspected and

found to be functioning normally; the team elected to preserve it and avoid re-replacement. Hemostasis was

achieved; the patient was rewarmed and weaned from cardiopulmonary bypass without difficulty.

The sternum was closed in standard fashion. Total CPB and selective cerebral perfusion times were

recorded; estimated blood loss and transfusion requirements were within acceptable limits. The procedure

proceeded electively without intraoperative complications.

Figure 1: Hemiarch and Innominate Artery Reconstruction

Postoperative course and follow-up

The patient was transferred to the cardiac intensive care unit. He was extubated on postoperative day (POD)

1 with a normal neurologic exam and NIRS values. Early physiotherapy and mobilization were initiated on

POD 2. Anticoagulation (warfarin) was resumed per standard protocol for mechanical valve protection after

ensuring hemostasis. There were no postoperative strokes, spinal cord ischemia, re-explorations for

bleeding, wound infections, or renal dysfunction. Renal function, liver function, and coagulation profiles

remained within acceptable limits. CTA at postoperative follow-up (prior to discharge) demonstrated a

patent ascending aortic graft with intact anastomoses and a patent reconstructed innominate artery without

narrowing or leak. The patient was discharged on POD 7 in stable condition with instructions for routine

surveillance imaging. At 3-month clinical and imaging follow-up, the patient remained asymptomatic, with

stable graft appearance on CTA and no neurologic or cardiopulmonary abnormalities.

Suchitran M et al | DOI: 10.65188/nurexus.1063

Page 22

Discussion

This case highlights important contemporary considerations in the management of combined ascending

aortic aneurysm and innominate artery aneurysm after prior aortic valve replacement, and demonstrates the

feasibility of elective redo sternotomy with hemiarch replacement and innominate artery reconstruction in

carefully selected patients.

Progressive dilatation of the ascending aorta following aortic valve replacement is increasingly recognized

and is influenced by multiple factors, including intrinsic aortopathy, altered hemodynamic flow patterns,

and systemic hypertension. Current guideline recommendations emphasize the importance of long-term

imaging surveillance in patients following aortic valve replacement because of the persistent risk of aortic

enlargement and late complications Isselbacher et al. [3]. Large ascending aortic aneurysms detected

several years after valve surgery have been reported in contemporary series, underscoring the need for

ongoing vigilance Dregoesc et al. [1]. Advances in postoperative imaging protocols now allow earlier

identification of progressive aortic disease and timely elective intervention Ahmed et al. [2].

Innominate artery aneurysms are rare but clinically significant vascular lesions. They are often incidentally

detected on cross-sectional imaging and may remain asymptomatic until complications such as rupture,

thromboembolism, or compressive symptoms occur Jeon et al. [5]; Hong et al. [7]. Recent case series and

single-center reports have documented diverse etiologies, including degenerative, inflammatory, and

mycotic causes, with successful surgical or endovascular management depending on anatomical

considerations and infective status Inam et al. [9]; Johari et al. [10]; Cinà et al. [21]. Contemporary surgical

techniques for innominate artery reconstruction, including translocation and reimplantation, have

demonstrated favorable outcomes when performed in specialized centers Phothikun et al. [11]. Although

endovascular repair has been described in selected cases, open reconstruction remains the preferred

approach for complex proximal arch involvement or when concomitant ascending aortic replacement is

required Dang et al. [4]; Fridling et al. [20].

Redo sternotomy for aortic surgery is associated with increased operative risk due to mediastinal adhesions

and potential injury to prior grafts or prosthetic valves. Contemporary analyses continue to highlight these

challenges while demonstrating improved outcomes with careful patient selection and meticulous surgical

planning Fudulu et al. [12]; Akintoye et al. [22]. Hemiarch replacement has emerged as a pragmatic surgical

option for localized proximal arch pathology and is associated with acceptable in-hospital mortality and

neurologic event rates in modern series Pearsall et al. [13]; Yamabe et al. [14]. Compared with more

extensive arch reconstructions, limited arch replacement reduces cerebral ischemic time when disease

extent permits, without compromising medium-term outcomes Yamabe et al. [14]; Krishnan et al. [16]. In

the present case, the decision to perform hemiarch replacement with selective innominate artery

reconstruction was guided by preoperative computed tomography morphology, absence of distal arch

disease, and the presence of a well-functioning prosthetic aortic valve, enabling a focused and less invasive

repair. Optimized cerebral protection is a cornerstone of contemporary aortic arch surgery. Recent reviews

and meta-analyses have detailed the benefits of antegrade cerebral perfusion strategies, including unilateral

and bilateral approaches, as well as the adjunctive role of neuromonitoring using near-infrared spectroscopy

to tailor perfusion parameters Abjigitova et al. [17]; Werner [12]. In the present case, selective antegrade

cerebral perfusion combined with near-infrared spectroscopy-guided monitoring was employed, consistent

with current best practices to minimize neurologic complications during arch reconstruction.

Recent literature indicates that redo aortic procedures, when performed electively at experienced centers

using modern techniques, can achieve acceptable morbidity and mortality rates Fudulu et al. [12]; Akintoye

Suchitran M et al | DOI: 10.65188/nurexus.1063

Page 23

et al. [22]; Shrestha et al. [23]. Comparative studies evaluating limited versus extensive arch replacement

strategies have demonstrated that hemiarch replacement in appropriately selected patients is associated with

shorter operative times and similar medium-term reintervention rates Krishnan et al. [16]; Yamabe et al.

[14]. The uneventful postoperative recovery observed in our patient aligns with these findings and supports

the role of targeted repair in young patients following aortic valve replacement. Reconstruction of the

innominate artery during aortic surgery requires individualized planning based on aneurysm morphology,

vessel length, and tissue quality. Contemporary reports describe various techniques, including

translocation, reimplantation, and interposition grafting, with favorable outcomes in experienced hands

Phothikun et al. [11]. Additional series emphasize tailoring the reconstructive approach according to

proximity to the vessel origin and involvement of adjacent arch segments Jeon et al. [5]; Hong et al. [7]. In

the present case, direct reimplantation of the innominate artery into the prosthetic ascending aortic graft

achieved anatomical restoration of cerebral blood flow with a durable anastomosis.

Long-term surveillance following aortic valve replacement remains critical for early detection of

progressive aortic pathology. Contemporary guideline updates reiterate the importance of structured

imaging follow-up and clearly defined intervention thresholds, Isselbacher et al. [3]. Advanced imaging

strategies have improved the ability to detect subtle changes in aortic dimensions and facilitate timely

elective repair, thereby avoiding emergency surgery with its associated higher risk Ahmed et al. [25];

Borger et al. [15]. In the present case, routine follow-up imaging enabled elective surgical intervention at

an optimal time, contributing to a favorable outcome. This report describes a single case, and the findings

may not be generalizable to patients with extensive arch involvement, active infection, poor physiological

reserve, or hostile mediastinal anatomy. Furthermore, outcomes may vary depending on institutional

experience and the availability of multidisciplinary expertise. Referral to specialized aortic centers should

be considered for complex redo arch procedures when feasible

Summary

This case report describes the successful management of a young adult with a prior history of aortic valve

replacement who developed a combination of ascending aortic aneurysm and innominate artery aneurysm

detected on routine surveillance imaging. The coexistence of these pathologies presents significant

diagnostic and surgical challenges, particularly in the setting of redo sternotomy. A carefully planned

elective redo median sternotomy with ascending aorta and hemiarch replacement, along with selective

innominate artery reconstruction, was performed using contemporary cerebral protection and intraoperative

monitoring strategies. The patient had an uneventful postoperative course with no neurological or surgical

complications and demonstrated excellent early recovery. This case underscores the importance of long-

term imaging surveillance after aortic valve replacement and highlights the feasibility of limited arch repair

with supra-aortic vessel reconstruction in appropriately selected patients.

Conclusion

Progressive ascending aortic dilatation and associated supra-aortic vessel aneurysms can occur years after

aortic valve replacement and may remain clinically silent until identified through routine surveillance. This

case demonstrates that elective redo sternotomy with ascending aorta and hemiarch replacement combined

with innominate artery reconstruction can be performed safely and effectively in selected patients when

guided by meticulous preoperative planning, appropriate cerebral protection, and experienced

multidisciplinary care. Early detection and timely intervention are critical in preventing life-threatening

complications and achieving favorable surgical outcomes. Lifelong follow-up with structured imaging

protocols should be considered an essential component of care in patients following aortic valve

replacement.

Suchitran M et al | DOI: 10.65188/nurexus.1063

Page 24

Conflict of interest: Nil

Source Of Fund: Nil

Reference

1. Dregoesc MI, Nistor I, Popescu OR. Giant ascending aortic aneurysm after aortic valve replacement: a case

report and contemporary review. J Card Surg. 2020;35(12):3456–3460.

2. Ahmed Y, Ghotbi N, Lloyd C, et al. Imaging surveillance after open thoracic aortic repair: feasibility, timing,

and clinical impact. Eur J Vasc Endovasc Surg. 2021;61(4):505–514.

3. Isselbacher EM, Preventza O, Hamilton Black J III, et al. 2022 ACC/AHA guideline for the diagnosis and

management of aortic disease. Circulation. 2022;146(15):e334–e482.

4. Dang T, Oderich GS, Pochettino A, et al. Endovascular management of innominate artery aneurysms and

injuries: indications, techniques, and outcomes. Vasc Endovasc Surg. 2022;56(5):357–368.

5. Jeon BH, Park SJ, Cho SW. Surgical treatment of an innominate artery aneurysm using cerebral oximetry

monitoring: a case report. J Chest Surg. 2021;54(2):134–140.

6. Cinà CS, Arena GO, Bruin G, Clase CM. Supra-aortic trunk aneurysms: contemporary diagnosis and

management strategies. Ann Vasc Surg. 2021;70:244–255.

7. Hong YK, Lee SG, Kim JS. Surgical management of a giant innominate artery aneurysm causing tracheal

compression. Korean J Thorac Cardiovasc Surg. 2022;55(3):145–150.

8. Prendes CF, Ultee KHJ, Schermerhorn ML. Hybrid and open repair of innominate artery aneurysms: current

concepts. Ann Vasc Surg. 2021;72:451.e1–451.e6.

9. Inam H, Al-Jundi W, Khan A. Autologous vein graft repair of a mycotic innominate artery aneurysm in a

young adult. J Vasc Surg Cases Innov Tech. 2023;9(1):45–50.

10. Johari HG, Rahman A, Singh M. Ruptured innominate artery pseudoaneurysm presenting with compressive

mediastinal symptoms: a case report. J Med Case Rep. 2022;16:123.

11. Phothikun A, Bavaria JE, Desai ND. Innominate artery translocation with hemiarch replacement: operative

technique and outcomes. Eur J Cardiothorac Surg. 2024;65(1):120–128.

12. Fudulu DP, Angelini GD, Benedetto U, et al. Outcomes and predictors following redo aortic root and

sternotomy procedures: a contemporary registry analysis. Front Cardiovasc Med. 2024;11:1295968.

13. Pearsall E, Etz CD, Kari FA, et al. Long-term outcomes of hemiarch replacement for proximal aortic

pathology. Ann Thorac Surg. 2022;113(3):814–822.

14. Yamabe T, Handa N, Okita Y. Extent of aortic arch replacement and operative outcomes: hemiarch versus

extended arch repair. JTCVS Open. 2022;10:99–108.

15. Borger MA, Preston M, Ivanov J, et al. Surveillance and management of ascending aortic dilation after aortic

valve interventions. J Thorac Cardiovasc Surg. 2021;161(1):12–21.

16. Krishnan A, Sultan I, Navid F, et al. Outcomes after concomitant hemiarch replacement during proximal

aortic surgery. Eur J Cardiothorac Surg. 2023;64(5):1203–1211.

17. Abjigitova D, Etz CD, Czerny M. Cerebral protection strategies in aortic arch surgery: a systematic review

and meta-analysis. Interact Cardiovasc Thorac Surg. 2022;35(3):ivac128.

18. Werner P, Czerny M. Cerebral protection in modern aortic arch surgery: current evidence and future

directions. J Thorac Dis. 2024;16(2):123–139.

19. Shrestha M, Martens A, Kaufeld T, et al. Redo aortic arch surgery: patient selection and contemporary

outcomes. Eur J Cardiothorac Surg. 2023;64(2):226–235.

20. Fridling J, Reijnen MMPJ, Zeebregts CJ. Endovascular treatment of innominate artery aneurysms: a

contemporary case series. Ann Vasc Endovasc Surg. 2025;9(1):1–11.

21. Johari HG, Rahman A. Supra-aortic aneurysms: clinical spectrum and management outcomes. Ann Vasc

Surg. 2022;79:88–96.

22. Akintoye E, Ando T, Adegbala O, et al. Early and mid-term outcomes following redo thoracic aortic surgery.

J Cardiothorac Surg. 2024;19:95.

23. Fudulu DP, Benedetto U, Angelini GD. Reoperative aortic surgery: risks, outcomes, and contemporary

strategies. Front Cardiovasc Med. 2024;11:1295975.

Suchitran M et al | DOI: 10.65188/nurexus.1063

Page 25

24. Dang T, Oderich GS. Endovascular approaches to supra-aortic trunk pathology: current status. Semin Vasc

Surg. 2022;35(4):240–248.

25. Ahmed Y, Lloyd C, Patel R, et al. Advanced CT imaging for postoperative surveillance of thoracic aortic

disease. Eur J Radiol. 2021;141:109818.