Pyramidal Angulation of the Ascending Aortic Graft: Recurrent Emboli After Type A Repair

Background: We report a unique case of recurrent cerebrovascular events under adequate anticoagulation, in the absence of a visible thrombus, due to a severely kinked ascending aortic graft after type A dissection repair. Case Summary: A 70-year-old man developed 4 transient ischemic attacks and 3 ischemic strokes over 4 years despite therapeutic rivaroxaban levels and prior antiplatelet therapy. Imaging revealed a kinked ascending graft without thrombus. High-risk redo surgery was pursued to correct graft geometry, after which no further embolic events occurred during early follow-up (5 months). Discussion: This case addresses the clinical dilemma whether a visible thrombus is required to justify redo surgery after type A repair, especially when recurrent embolism occurs under maximal medical therapy. Take-Home Message: Surgical correction of graft kinking may be indicated—even in the absence of a thrombus—when embolic risk persists under optimal anticoagulation.