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Prevention of late type Ia endoleaks is the main concern in thoracic endovascular aortic aneurysm repair (TEVAR) for thoracic aortic aneurysm. Since 2017, we have performed zone 0 TEVAR with proximal fixation augmentation using a Najuta thoracic fenestrated stent graft in addition to zone 2 TEVAR for distal arch aneurysms. We report the early and midterm outcomes of TEVAR performed using this strategy. This single-center retrospective study enrolled 386 cases of TEVAR for thoracic aortic disease between January 2013 and December 2020. Patients with thoracic aortic aneurysm treated by TEVAR landing at zone 2 was referred to as the standard group, whereas those treated by TEVAR landing at zone 0 using a Najuta fenestrated stent graft in addition to zone 2 TEVAR was referred to as the augmentation group. We retrospectively compared the clinical outcomes between the two groups. The primary end point was secondary intervention for postoperative type Ia endoleaks. Secondary end points were technical success, aneurysm-related death, and major adverse events (MAEs), including stroke, paraplegia, endoleaks, and secondary interventions. We performed TEVAR in 41 and 30 cases in the standard and augmentation groups, respectively. The mean aneurysm sizes in the standard and augmentation groups were 54.5 and 57.3 mm (P =.23), and the proximal neck lengths were 16.8 and 17.4 mm (P =.65), respectively. The anatomical characteristics seemed to be similar in both groups. The technical success rate in both groups was 100%. Three cases in the standard group had MAEs, including two stroke and one brachial artery pseudoaneurysm; whereas two cases had MAEs in the augmentation group, including one stroke and one paraplegia. There was no 30-day mortality or retrograde type A dissection in both groups. The mean observation periods in the standard and augmentation groups were 46 months (range, 1-123 months) and 35 months (range, 1-73 months), respectively. At 36 and 60 months after the procedure, the freedom from aneurysm-related death was 97.6% and 97.6% in the standard group, 100.0% and 100.0% in the augmentation group (P =.39); and the freedom from reintervention for type Ia endoleaks was 79.2% and 65.2% in the standard group, 100.0% and 100.0% in the augmentation group (P =.0087). A statistically significant decrease in reinterventions for type Ia endoleaks was observed in the augmentation group. Proximal fixation augmentation using the Najuta fenestrated stent graft during TEVAR for distal arch aneurysm is effective in preventing the postoperative late type Ia endoleaks. [ABSTRACT FROM AUTHOR]

Abstract Background Aortic arch aneurysm is a very rare condition in children. Surgery is the life saving procedure but it performing might be challenging due to the complex anatomy. Case presentation We describe a 13-year-old girl who was diagnosed to have an isolated giant aortic arch aneurysm. This girl was referred to our institution with persistent cough as a leading symptom, which started two months ago. Surgery was performed as combined approach: left-sided thoracotomy and midline sternotomy. The left subclavian artery was re-implanted via supraclavicular approach to the left common carotid artery end-to-side anastomosis. Aneurysm was excised after midline sternotomy and initiation of cardiopulmonary bypass under mild hypothermia. Histological evaluation of the wall of the aneurysm revealed no evidence of any specific changes. Conclusions The using of the combined method was characterised by a good postoperative surgical results. Pediatricians should be aware of persistent cough in children as a symptom of mediastinal mass of different origin and identity.

Embedded modular branched stent graft (EMBSG) was a new option for aortic arch aneurysm. However, the therapeutic effect of this innovative stenting technique has not been fully assessed. Computational fluid dynamics and three-dimensional structural analyses were performed on three patients (Patient I, Patient II and Patient III) with aortic arch aneurysm, both before and after EMBSG implantation. Patient-specific alterations from preoperative to postoperative were analyzed via morphological and functional metrics. Patient I and Patient II showed notable curvature changes and area reduction after intervention procedure. Three patients showed an increase in flow velocity after EMBSG implantation, while the pressure drop from ascending aorta to the aortic arch was remarkable in Patient I and Patient II with the value of 7.09 ​mmHg, and 10.95 ​mmHg, respectively. Patient I and Patient II also showed elevated time-averaged wall shear stress (TAWSS) in the stenting region, while Patient III showed a trivial change in TAWSS after intervention procedure. Three patients showed low relative residence time after EMBSG insertion. The short-term results of EMBSG in treating aortic arch aneurysm were promising. Hemodynamic parameters have the potential to assist in the outcome evaluation and might be used to guide the stent graft design and wise selection, thereby improving the long-term therapeutic effect in managing complex vascular disease.

IntroductionThe frozen elephant trunk technique is a surgical procedure developed for concomitant repair of downstream descending thoracic aorta as a first stage operation for arch resections. Proximalization of the sutured anastomosis reduces technical difficulty of total arch replacement. In this procedure, an anastomosis is performed more proximally using a stent graft. Connect the head and neck vessels are created using in-situ fenestration method.Case presentationThis study presents the case of a 78-year-old woman with a large thoracic aortic arch aneurysm that was successfully treated with a modified frozen elephant trunk technique (open in situ fenestration). For this method, a hole was created in the neck branches (the left subclavian artery and left common carotid artery), and peripheral stent grafts were placed to simplify neck branch reconstruction. This minimized the risk of recurrent laryngeal nerve injury and bleeding and shortened the procedure time.ConclusionThe outcomes of this study showed a safe alternative total arch replacement procedure.

Background: Endovascular repair of thoracic aortic aneurysms (TAA) in elective settings has demonstrated successful clinical outcomes. However, life-threatening conditions such as rupture are more often managed with open surgical repair due to the high complexity of arch endovascular repair, lack of available off-the-shelf devices, and limited long-term data., Case Summary: A 49-year-old female with a recent history of prior ascending aortic repair for Type A 10 aortic dissection presented with chest pain and dyspnea. Chest computed tomography angiogram (CTA) revealed acute bilateral pulmonary emboli and a 6.2 cm post dissection aneurysm of the posterior aortic arch with the dissection extending to the right iliac artery. She was treated with thrombolysis and subsequently became hemodynamically unstable. Repeat CTA revealed a massive left hemithorax with concern for aortic arch rupture. Given significant cardiorespiratory compromise and recent open repair, she was considered unfit for redo open repair. Thoracic endovascular aortic repair (TEVAR) with a physician-modified endograft (PMEG) was planned. An Alpha Zenith endograft was modified adding an internal branch for the innominate artery and a fenestration for the left common carotid artery. The left subclavian artery was occluded with a microvascular plug and coil embolization up to the level of the vertebral artery. TEVAR PMEG extension to the celiac artery was performed followed by deployment of a Zenith dissection stent to the aortic bifurcation. Completion angiogram demonstrated successful aneurysm exclusion and patency of target vessels., Conclusion: Endovascular treatment of ruptured TAA with PMEGs is feasible. This approach may be an alternative for unfit patients for open repair in emergent settings., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: M.L.K. is a consultant for W. L. Gore & Associates. M.S.B. has received research support from Cook Medical Inc, W.L. Gore & Associates. C.H.T. has been a consultant for and received research support from Cook Medical Inc, W.L. Gore & Associates and Phillips Healthcare.

Background: Changes in stent graft (SG) orientation after frozen elephant trunk (FET) treatment for aortic arch aneurysms are not well understood. This study investigated changes in SG orientation and their effects on aortic events after FET for aortic arch aneurysms., Methods: This study included 57 patients with true aneurysms who underwent elective total arch replacement using FET between 2016 and 2023. Postoperative SG angle, descending aortic (DA) diameter at the end of the SG, and the DA angle were measured retrospectively by using enhanced computed tomography (CT)., Results: Median patient age was 74 years. The median stent size was 33 mm, and the stent length was 12 cm (range, 23-37 mm and 6-15 cm). Enhanced CT showed that all the patients had completely thrombosed aneurysms after the procedure. Aortic events (dissection or type Ib leaks) were observed in four patients during the follow-up period. The diameter of the DA at the end of the SG and the DA angle increased in recent periods (P=0.04 and P=0.01, respectively). The SG angle changed to an obtuse angle in the recent periods (P<0.0001). The probability of postoperative aortic events did not correlate with changes in SG orientation but with the ratio of recent postoperative descending diameter to preoperative descending diameter (P=0.04)., Conclusions: The descending aorta into which the SG was inserted showed flattening and widening movements owing to the spiring back force. One of the factors related to aortic events was dilation of the postoperative DA due to oversizing of the SG., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1169/coif). The authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Although retrograde in situ branched stent grafting (RIBS) is one possible treatment option for thoracic aortic aneurysms, concerns exist regarding the durability of the stent graft (SG) at the junction between the main SG and the branched SG. We report on the autopsy results of a patient treated with RIBS for a complex aortic arch aneurysm. The patient had died of a nonaortic cause 14 months after the RIBS procedure. On computed tomography analysis and a leak test, the harvested SG was intact without any stent fracture, stenosis, or junctional leak at 1 atm water pressure (760 mm Hg).

Abstract Background Cold agglutinin disease can lead to significant complications, especially for patients undergoing arch repair requiring hypothermic circulatory arrest. Rituximab and plasmapheresis are treatments for cold agglutinin disease. However, its use in patients with Stanford type A dissection has not been reported. Therefore, after consultation with hematologists, we used rituximab and plasmapheresis before mild hypothermic aortic arch surgery to maintain the body temperature above the thermal altitude. Case presentation This report describes an 86-year-old male patient with acute type A aortic dissection who received outpatient treatment for rheumatoid arthritis and a 55-mm thoracic aortic aneurysm. The patient was scheduled to undergo urgent surgery for a type A intramural hematoma and progressive aortic aneurysm; however, laboratory test results indicated blood clotting and cold agglutinin. Consequently, urgent surgery was rescheduled. After consulting with hematologists, rituximab was initiated 3 months before surgery, and plasmapheresis was performed 2 days before surgery for cold agglutinin disease. Under mild hypothermia conditions, total arch replacement using the frozen elephant trunk technique was performed while maintaining cerebral and lower body perfusion. The postoperative course was uneventful. On postoperative day 42, the patient was discharged without any neurological deficits. Conclusions This case involving total arch replacement with mild hypothermia for an aortic arch aneurysm with cold agglutinin disease after rituximab treatment and plasmapheresis resulted in a successful outcome.

Background: Ortner's syndrome, also known as cardio-vocal cord syndrome, is characterized by vocal cord paralysis secondary to compression of recurrent laryngeal nerve from a cardiopulmonary lesion. Clinicians may fail to diagnose or misdiagnose Ortner's syndrome because of its low incidence and complex pathogenesis. Here, we report a patient with an aortic arch aneurysm presenting solely with vocal cord paralysis and review existing literature to better understand Ortner's syndrome pathogenesis. Case presentation: On August 23, 2021, a 74-year-old man with cholecystolithiasis and acute cholecystitis was admitted to the Department of Hepatobiliary Surgery, at the First Affiliated Hospital of Jinan University. During medical history collection and physical examination, the patient's voice was unexpectedly hoarse. The patient then underwent laryngoscopy, computed tomography (CT) scanning of the chest, and enhanced CT scanning. Three-dimensional reconstruction of the thoracic aorta revealed an unstable aneurysm at the anterior of the aortic arch. The left recurrent laryngeal nerve was compressed by the aneurysm, leading to left vocal cord paralysis and voice hoarseness. Discussion: Hoarseness caused by vocal cord paralysis suggests damage to the recurrent laryngeal nerve. Examination based on the anatomical path, from the base of the skull to the diaphragm, especially from the vagus nerve origin area to the end of the recurrent laryngeal nerve, is helpful for early diagnosis of neck and thoracic cavity disorders, which could prevent misdiagnosis of acute and critical diseases.

We present a case of a 62-year-old male patient with chronic distal aortic arch aneurysm causing recurrent nerve palsy and prolonged total occlusion of the left main pulmonary artery (PA). During diagnostic work up, the aneurysm ruptured requiring cardio-pulmonary resuscitation (CPR) and emergency retrograde stenting. After circulatory stabilization the patient was treated with controlled hypothermia for 24 h, and successive extubation without neurological deficit.Postinterventional imaging revealed a reversed perfusion of the aneurysmal sac through the PA, prompting open surgical treatment. Surgery consisted of reconstruction of the left PA by pulmonary endarterectomy (PEA), xenopericardial patchplasty of the left PA and frozen elephant trunk (FET) repair after removal of the bare springs of the previously inserted Gore Tag stent graft. Pre-discharge computed tomography angiography (CTA) demonstrated a fully recanalized left PA system and a completely excluded aneurysm. At ten-year follow-up the patient presented physically unimpaired (NYHA I). CTA confirmed a fully intact thoracic aorta and improved pulmonary function despite persisting left recurrent nerve palsy.

A 43-year-old male was admitted to General Hospital of Northern Theater Command with exacerbation of chest pain for 10 d. Computed tomographic angiography (CTA) showed an irregular aortic arch aneurysm involving the left subclavian artery (LSA), with penetrating aortic ulcer and intramural hematoma. A modified fenestrated thoracic endovascular aortic repair (TEVAR) technique was performed successfully. Follow-up CTA showed that stent grafts were well-apposed, without endoleaks, migration, or branch artery occlusion, and the hematoma was almost completely absorbed. In this case, precise fenestrations were created by measurements based on three-dimensional CT reconstruction and angiography. Furthermore, the physician chose an LSA approach to catch the guide wire and deployed branched stent grafts, considering the oblique direction of this branch and the small size of the fenestration. This case shows that pre-fenestrated and inner bare stent enhancing TEVAR is a safe and feasible technique for repair of complicated aortic arch aneurysm.

Polycystic kidney disease (PKD) is a genetic disease characterized by the formation of multiple cysts in bilateral kidneys. While renal complications are predominant, cardiovascular manifestations such as aortic aneurysms can also occur. Although there are a few case reports of giant aortic arch aneurysms, to the best of our knowledge, this has been rarely reported in patients with PKD. Additionally, the clinical presentation of the index case is unique., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Institutional Ethics Committee of All India Institute of Medical Sciences, Bathinda, issued approval AB/IEC/Res/24/6456. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Wander et al.)

Introduction and Importance: Elderly and frail patients with thoracic aortic aneurysms (TAAs) near to origins of cervical arteries present facing challenges with aortic arch replacement with cardiopulmonary bypass, and traditional tube-type stent-grafts are also inadequate for transcatheter endovascular aortic repair (TEVAR). Thus, necessitating precise treatment with fenestrated stent-grafts from zone 0. This approach is crucial for achieving favorable postoperative outcomes without compromising activities of daily living (ADL)., Case Presentations: An 85-year-old-man admitted to the hospital for treatment of a large TAA. While arch replacement is a definitive procedure, it is highly invasive, and the postoperative ADL are expected to be significantly lower than preoperative levels. Therefore, we performed a debranching TEVAR from Zone 0 with fenestrated stent-graft. The patient was discharged from the hospital on the 11th postoperative day., Clinical Discussion: In frail and elderly patients for whom conventional surgery may not be viable, TEVAR emerges as a preferred alternative. However, TEVAR of TAA proximal to the aortic arch continues to pose challenges, necessitating meticulous attention to the cervical branches in the intervention strategy. While surgical intervention in these patients necessitates careful consideration of its suitability, including the potential for postoperative enhancement in ADL, the use of fenestrated stent-grafts from Zone 0 emerges as one of the treatment modalities., Conclusion: The authors present a very elderly case in which fenestrated stent-grafts were used to avoid aortic arch replacement for a large aortic arch aneurysm, resulting in a good postoperative course with no decline in ADL., Competing Interests: Not applicable., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Although aortic aneurysm is associated with vascular aging and atherosclerosis, carotid and intracranial vascular disease prevalence in patients with aortic arch aneurysm remains unclear. Similarly, the effect of carotid and intracranial lesions on postoperative outcomes is unknown. This study aimed to investigate the prevalence of carotid artery stenosis and intracranial lesions in patients with aortic arch aneurysm and its association with intraoperative regional cerebral oxygen saturation (rScO2) and postoperative neurological outcomes, including delirium and cerebral infarction., Methods: This retrospective observational study included 133 patients with true aortic arch aneurysm who underwent preoperative magnetic resonance imaging (MRI). We evaluated the prevalence of carotid and intracranial arterial lesions. Symptomatic cerebral infarction and delirium, defined by the confusion assessment method for the intensive care unit, were evaluated for their association with preoperative cerebrovascular lesions. Additionally, changes in regional saturation of the cerebral tissue at different surgical phases were evaluated for patients with and without cerebrovascular lesions., Results: Fifteen (11.3%) patients experienced symptomatic cerebral infarction, and 64 (48.1%) had postoperative delirium. Preoperative MRI showed old infarction, microbleeds, significant carotid artery stenosis, and intracranial lesions in 21.1%, 14.3%, 10.5%, and 7.5% of the patients, respectively. White matter hyperintensities with Fazekas scale 2 were observed in 40.6% of the patients, while Fazekas scale 3 were observed in 18.8% of the patients. Preoperative MRI findings and postoperative neurological outcomes were not significantly different. Seventy-six patients underwent rScO2 monitoring intraoperatively. Changes in rScO2 in patients with and without carotid/cerebrovascular lesions were not significantly different. However, rScO2 was significantly lower in patients who developed cerebral infarction., Conclusions: Significant carotid artery stenosis and intracranial lesions were observed in 10.5% and 7.5% of the patients, respectively. Although preoperative MRI findings and changes in rScO2 or postoperative outcomes showed no significant association, patients with postoperative cerebral infarction showed significantly lower rScO2 intraoperatively., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-78/coif). A.Y. received consulting fee from Japan Lifeline Co. Ltd. The other authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Abstract We report the case of an endovascular repair of an aortic arch aneurysm by a surgeon-modified fenestrated endograft with a single fenestration in a high-risk patient unfit for open surgery. A patient of 84 years, chronic ischemic cardiopathic, suffering from prostate adenocarcinoma in chemotherapy treatment, came to our hospital for post-traumatic fracture of the right femur. During the hospitalization, the patient exhibited dysphonia and respiratory disorders for several days, therefore, the patient performed Computed Tomography Angiography (CTA) that found the presence of voluminous aneurysm of the aortic arch with a maximum diameter of about 74 mm. The patient was treated with a hybrid-staged procedure; in the first instance, with a carotid-carotid-succlavium bypass to preserve the cerebral and upper limb vascularization and then, the procedure was completed by implanting the surgeon-modified fenestrated endograft with stent delivery to the patient with a fenestration on the anonymous trunk. This surgeon-modified fenestrated endograft was created by modifying a standard endograft by a single fenestration following the three-dimensional reconstructions of the CTA images. The procedure was successfully completed and postoperative course was uneventful. Computed Tomography Angiography demonstrated the exclusion of the aneurysm, patency of the implanted endograft modules, and absence of signs of endoleaks and / or cerebral or medullary ischemic complications.

In recent years, mycotic aortic aneurysms have been increasingly treated successfully by endovascular means. The introduction of custom-made fenestrated and branched devices, parallel graft techniques, and in situ fenestration has enabled total endovascular treatment also for arch pathologies. We describe a total endovascular repair of a mycotic arch aneurysm with in situ laser fenestration using venoarterial extracorporeal membrane oxygenation to preserve flow to vital organs.

Background: To establish a canine model of aortic arch aneurysm that is suitable for research on new devices and techniques applied to the aortic arch. Materials and methods: Fifteen mongrel dogs underwent surgery. The autologous pericardial patch was sewn on the aortotomy site in the anterior wall of the aortic arch. The animals were followed up for 3 months postoperatively. Computed tomography angiography was used to visualize and measure the aneurysm model. Hematoxylin and eosin staining was used to observe the histological characteristics of the aneurysm model. Changes in aneurysm diameter over time were analyzed using analysis of variance. Results: One dog died of hemorrhage during surgery. Fourteen dogs survived the surgical procedure. Two of them died on the first postoperative day because of ruptures at the suturing margin. The diameter of the aneurysm model was twice as large as that of the aortic arch. There was no significant change in the maximum diameter of the aneurysm model during the follow-up period. Conclusions: We established a controllable and stable aortic arch aneurysm model created with an autologous pericardium patch. The aneurysm model can be used to research endoleaks after thoracic endovascular aortic repair and new endovascular techniques can be applied to the aortic arch.

Abstract Background Infected aortic arch aneurysms caused by Mycobacterium avium are rare in immunocompetent individuals. Promptly recognizing these aneurysms is important because delays in treatment result in aneurysm rupture and a high fatality rate. Although Salmonella species, Streptococcus species, Staphylococcus aureus, and S. epidermis are commonly found in immunocompetent individuals, to our knowledge, infected aortic arch aneurysms caused by M. avium have not yet been reported. Case presentation We report the case of a 63-year old immunocompetent man who underwent total arch replacement following infection by the nontuberculous mycobacteria M. avium. The procedure involved total aneurysmal resection and arch replacement with a rifampicin-bonded gelatin-sealed woven Dacron graft. He was discharged without complications and remained asymptomatic after 30 months. Conclusion In this brief report, we outline and discuss the rare successful case of total arch replacement using total aneurysmal resection and rifampicin-bonded gelatin-sealed woven Dacron graft for an infected aortic arch aneurysm resulting from M. avium in an immunocompetent patient.

A 65-year-old woman had presented with a ruptured type B intramural hematoma associated with a right-sided aortic arch aneurysm, a large Kommerell diverticulum (KD) and an aberrant left subclavian artery (LSA). She underwent total aortic arch replacement with elephant trunk, thoracic endovascular aortic repair, and LSA ligation distal to the left vertebral artery. She subsequently developed a brisk type II endoleak into the KD via retrograde flow from the left vertebral artery. Percutaneous access of the left internal mammary artery with coil embolization of the proximal LSA and KD was performed. At 5 years, computed tomography angiogram showed complete thoracic aortic remodeling without an endoleak. The results from the present case have illustrated the novel use of the left internal mammary artery as an alternative access for LSA embolization in patients with type II endoleak and limited access options.

Objectives: The decision to undergo aortic aneurysm repair balances the risk of operation with the risk of aortic complications. The surgical risk is typically represented by perioperative mortality, while the aneurysmal risk relates to the 1-year risk of aortic events. We investigate the difference in 30-day and 1-year mortality after total arch replacement for aortic aneurysm., Methods: This was an international two-centre study of 456 patients who underwent total aortic arch replacement for aneurysm between 2006 and 2020. Our primary end-point of interest was 1-year mortality. Our secondary analysis determined which variables were associated with 1-year mortality., Results: The median age of patients was 65.4 years (interquartile range 55.1-71.1) and 118 (25.9%) were female. Concomitantly, 91 (20.0%) patients had either an aortic root replacement or aortic valve procedure. There was a drop in 1-year (81%, 95% confidence interval (CI) 78-85%) survival probability compared to 30-day (92%, 95% CI 90-95%) survival probability. Risk hazards regression showed the greatest risk of mortality in the first 4 months after discharge. Stroke [hazard ratio (HR) 2.54, 95% CI (1.16-5.58)], renal failure [HR 3.59 (1.78-7.25)], respiratory failure [HR 3.65 (1.79-7.42)] and reoperation for bleeding [HR 2.97 (1.36-6.46)] were associated with 1-year mortality in patients who survived 30 days., Conclusions: There is an increase in mortality up to 1 year after aortic arch replacement. This increase is prominent in the first 4 months and is associated with postoperative complications, implying the influence of surgical insult. Mortality beyond the short term may be considered in assessing surgical risk in patients who are undergoing total arch replacement., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

A 67-year-old male was admitted to our hospital for sudden onset chest pain and hoarseness. He underwent 2-debranching thoracic endovascular aortic repair for a ruptured aortic arch aneurysm four years prior. However, computed tomography (CT) revealed an aneurysmal rerupture due to a typeⅠa endoleak. We performed partial arch replacement with uncovered stent removal under intermittent hypothermic circulatory arrest. We needed to be more careful than usual open heart surgery because a non-anatomical bypass procedure was performed. The surgery was successful without any major complications, and the patient was discharged on the 23th postoperative day. Reinterventions post-endovascular repair are sometimes difficult;thus, open surgery could be useful for arch replacement.

A ruptured aortic arch aneurysm is imminently fatal unless expeditiously intervened. Hybrid thoracic endovascular aneurysm repair has revolutionized the therapeutic paradigm, in a complex clinical setting, in particular, compared to demanding and particularly riskier open reconstruction with its attendant cardiac and neurological sequelae. Herein, we describe a 52-year-old male who presented with a ruptured aortic arch aneurysm and concomitant innominate artery aneurysm with occluded left common carotid artery (CCA). Computed tomography (CT) aortogram visualized large retrosternal hematoma precluding sternotomy without circulatory arrest and distal end of aneurysm abutting ostium of theleft subclavian artery (LSA). Therefore, staged reimplantation of LSA to descending thoracic aorta (DTA) and extra-anatomic LSA to right CCA bypass were performed through posterolateral thoracotomy followed by Zone 0 deployment of the aortic stent graft. The patient keeps good health and remains asymptomatic at 2 years of follow-up. Repeated CT aortogram done immediate postoperatively and at 13 months showed patent graft and no endoleak. Hybrid arch repair by supra-aortic debranching facilitated by distalized LSA on DTA is a viable therapeutic option in patients with complex arch and innominate artery aneurysms that mandate Zone 0 coverage during endovascular aneurysm repair.