Distalization of left subclavian artery for cerebral revascularization during hybrid repair of complex and contained rupture of aortic arch aneurysm

Abstract

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.