Transaxillary access for ascending aortic and root surgery: a single-center comparison with full and partial sternotomy

Background: Minimally invasive approaches for ascending aortic and root surgery remain controversial regarding operative complexity and safety. The transaxillary (TAX) approach avoids sternotomy entirely but has not been compared with both full sternotomy (FS) and partial upper sternotomy [minimally invasive cardiac surgery (MIC)]. This study evaluates perioperative outcomes across these three access strategies. Methods: Between January 2022 and December 2025, 194 consecutive patients undergoing elective isolated ascending aortic or root surgery were retrospectively analyzed. Surgical access was FS (n=52), MIC (n=106), or TAX (n=36). TAX suitability was assessed by team consensus on electrocardiogram (ECG)-gated computed tomography (CT). Primary endpoints were in-hospital mortality, major complications [Society of Thoracic Surgeons (STS) composite], and hospital length of stay. TAX was compared with MIC after 1:2 propensity score matching. FS served as descriptive reference. Results: FS patients had higher EuroSCORE II (median 2.7 vs. MIC 2.2 vs. TAX 2.3%, P=0.006). Cardiopulmonary bypass time was longer in TAX {196 [interquartile range (IQR): 175–239] vs. MIC 160 [138–192] vs. FS 172 [140–198] min, P<0.001}, while cross-clamp time did not differ (P=0.34). In-hospital mortality was 3.8% (FS), 0% (MIC), and 0% (TAX). Major complications occurred in 26.9%, 12.3%, and 8.3% (P=0.02), and acute kidney injury (AKI) in 28.8%, 8.5%, and 2.8% (P<0.001). One stroke occurred in the FS group. In the matched cohort (34 TAX vs. 68 MIC), bypass time remained longer in TAX {196 [175–240] vs. 160 [139–190] min, P<0.001}, whereas cross-clamp time, intensive care unit (ICU) and hospital stay, major complications (5.9% vs. 11.8%), AKI (2.9% vs. 10.3%), atrial fibrillation, and wound complications did not differ significantly. Conclusions: TAX ascending aortic and root surgery was feasible in carefully selected patients, with no in-hospital mortality, no stroke, and no wound complications. In a propensity-matched comparison with partial upper sternotomy, early outcomes did not differ significantly despite longer bypass time. TAX extends the sternal-sparing concept to the aortic root and ascending aorta and warrants prospective evaluation.