Surgical repair of aortic arch aneurysms is still an invasive procedure requiring arch replacement during deep hypothermic circulatory arrest. Endovascular aortic arch repair is less invasive compared with the open surgical aortic arch repair in treating aortic arch disease; this correlates with low morbidity and mortality rates, even in high-risk patients. Aortic arch diseases, such as aneurysms and dissections, often involve the origin of the supra-aortic branches. Surgical aortic arch debranching is therefore indicated before covering of these branches. On the other hand, an aberrant right subclavian artery is the most common abnormality arising in the development of the aortic arch. We describe an original method of revascularization followed by stent graft insertion in the case of ruptured aortic arch aneurysm with existing aberrant right subclavian artery. A 56-year-old woman was admitted to our emergency department because of chest pain, cough, and hemoptysis. At the time of admission, the blood pressure was 200/100 mm Hg; pulse rate was 115 beats/min. The initial laboratory findings showed hemoglobin level of 8.9 g/dL. The computed tomography scan showed a 6-cm fusiform aneurysm of the aortic arch 0.5 cm distal to the left carotid artery, extravasation of the contrast material from the posterior wall, and aberrant right subclavian artery (Fig 1). After a multidisciplinary team discussion, a decision was made to perform a hybrid procedure as a safer and more viable option than surgical replacement of the aortic arch. In our case, the hybrid procedure was performed in three steps: bilateral subclavian to carotid bypass with supraclavicular access, followed by midline sternotomy and aorta-bicarotid bypass (Dacron 16/8 mm) from ascending aorta, and finally implantation of an endovascular stent graft that completely covered the aortic arch. The operation was performed under brain oxygenation monitoring. No extracorporeal circulation was used. After the procedure, normal blood flow to the branches of the aortic arch was restored; the aortic aneurysm was completely isolated, and there was no endoleak (Fig 2). The patient was discharged 15 days after the operation with stable hemodynamics, without symptoms of neurologic deficiency and in a good general condition. Endovascular repair after aortic arch debranching has the potential to reduce the morbidity and mortality rates in patients with ruptured aortic arch aneurysm and abnormality of the supra-aortic branches.Fig 2Aorta-bicarotid bypass, bilateral subclavian to carotid bypass, and aortic stent graft.View Large Image Figure ViewerDownload Hi-res image Download (PPT)