Hybrid Repair of a Complex Distal Arch and Left Subclavian Artery Aneurysm

Complex distal aortic arch aneurysms involving the subclavian arteries present major challenges because of limited proximal landing zones and the need to protect cerebral and upper-extremity perfusion. This study presents a strategy that combines off-pump supra-aortic revascularization combined with thoracic endovascular aortic repair (TEVAR).

A 38-year-old woman with a large left subclavian artery aneurysm (61 × 55 mm) and a distal aortic arch underwent hybrid repair. Preoperative imaging revealed a right vertebral artery and complex arch anatomy. Three possible surgical options were considered:

1. Left thoracotomy with total circulatory arrest (TCA) and graft interposition
2. Median sternotomy with TCA
3. Frozen elephant trunk

The option that was selected was a median sternotomy with off-pump ascending to left coronary artery (LCA) bypass and TEVAR.

Through a sternotomy, an 8 mm prosthetic vascular graft was interposed from the ascending aorta to the left common carotid artery on the beating heart. Following this procedure, TEVAR was performed through the femoral artery. Since the initial endograft partially prolapsed into the sac, a second endograft was utilized to optimize arch apposition. Then, the left common carotid artery was ligated at its origin.

Angiographic evaluation showed patency of the common carotid bypass and the innominate artery, as well as the exclusion of major inflow to the aneurysmal sac. Only minimal delayed sac filling was observed. Due to the residual communication being sharply angulated and adjacent to the vertebral artery, immediate plug occlusion was considered unsuitable; therefore, the sac was managed expectantly. During subsequent follow-ups, a persistent left subclavian artery (LSA) filling was detected and was treated through coil embolization. Completion angiography following the embolization suggested elimination of the endoleak, allowing the patient to be managed without invasive treatment methods, including bypass, TCA, or open arch replacement.

This case demonstrates that hybrid repair as a surgical treatment method combined with TEVAR can provide a less invasive alternative for some patients with complex distal arch and subclavian artery aneurysms. Finally, hybrid repair is a safer treatment method for distal arch and subclavian artery aneurysms, which can be applied without the patient being exposed to TCA or other possible complications.

References

1. Chen CW, Hu J, Li YY, et al. The outcomes of aortic arch repair between open surgical repair and debranching endovascular hybrid surgical repair: a systematic review and meta-analysis. J Vasc Surg. 2024;79(6):1510-1524. PMID: 38122857.
2. Kawaharada N, et al. Endovascular and hybrid treatments for subclavian artery aneurysms. [PubMed-indexed study]. PMID: 35333775.
3. Sato T, et al. Coil-in-plug method for left subclavian artery embolization in thoracic endovascular aortic repair with arch vessel debranching. Ann Vasc Dis. 2023. PMID:37779651.
4. Peterson MD, Wheatley GH 3rd, Kpodonu J, et al. Treatment of type II endoleaks associated with left subclavian artery coverage during thoracic aortic stent grafting. JThorac Cardiovasc Surg. 2008 Nov;136(5):1193-9. doi: 10.1016/j.jtcvs.2008.05.036. Epub 2008 Sep 6. PMID: 19026802.
5. Fujioka S, Kitamura T, Mishima T, et al. Coil-in-Plug Method for Left Subclavian Artery Embolization in Thoracic Endovascular Aortic Repair with Arch Vessel Debranching. Ann Vasc Dis. 2023 Sep 25;16(3):189-194. doi: 10.3400/avd.oa.23-00012. PMID: 37779651; PMCID: PMC10539117.

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