This procedure is routinely performed via a full sternotomy or mini upper sternotomy. I have performed 4 such procedures in the last several months via a mini right thoracotomy approach (6 cm incision). There is no doubt that it has technical challenges. The distal anastomosis is not difficult. The aorta is transected at the level of the Arch and not beveled under the lesser curvature of the aorta. If you don’t consider this a hemi arch, that’ still OK because all of the diseased ascending aorta is resected. The only caveat is that this needs to be performed under circulatory arrest. I routinely utilize retrograde cerebral perfusion while on circulatory arrest. I would say that the proximal (supra-coronary) anastomosis is the most challenging. I have enclosed some pics of the procedure.
I performed 2 of these procedures this week during 2 separate Minimally Invasive training courses (Miami Heart Valve Updates)