Background and Aim: TEVAR has become the first choice treatment of thoracic aortic rupture. However, in some cases standard retrograde delivery can be prevented by severe aorto-ilio-femoral vascular disease. For these high-risk patients, left ventricular apex can be a valid alternative to achieve vascular access for stent-graft antegrade delivery. Here we report our experience and mid-term results with trans-apical TEVAR (Ta-TEVAR) in case of thoracic aortic rupture Methods: Since 2012 we performed Ta-TEVAR in six patients with acute aortic syndrome. Indication for urgent/emergent TEVAR was post-traumatic aortic injury in 2 patients, contained rupture in 3 patients and penetrating aortic ulcer with signs of impeding rupture in the last patient. In five patients standard retrograde delivery was prevented by severe and calcific ilio-femoral occlusive disease and in one patient with traumatic aortic transection due to severe polytrauma, by acute ischemia of both lower limbs following Resuscitative Endovascular Balloon Occlusion of the Aorta. Antegrade TEVAR through left ventricular apex in left anterior minithoracotomy was performed in all cases. Results: Successful deployment of the stent graft was achieved in all patients. No case of hemodynamic instability or bleeding from the cardiac apex was noted during the procedures. No case endo-leak or aorta-related mortality was noted during the follow-up (range 9–68 months). Conclusion: In patient with thoracic aortic rupture and unfeasible standard retrograde TEVAR, the trans-apical approach can be used safely even in an emergency setting. Study with bigger cohorts and longer follow up are necessary to further evaluate this alternative approach.