Hybrid TEVAR with Carotid–Subclavian Bypass as a Frontier in ChronicAortic Dissection Treatment in a Rural Area: A Case Report

BACKGROUND: Managing chronic type B aortic dissection (cTBAD) is difficult when the anatomy of the arch makes standard TEVAR impossible and advanced devices are not available. This is often the case in rural areas where referrals take a long time. CASE PRESENTATION: A 49-year-old male from rural Indonesia exhibited acute-on-chronic DeBakey III aortic dissection, complicated by critical right leg ischemia resulting from dynamic iliac obstruction. Prior instances of chest pain in 2019 were inaccurately diagnosed, postponing conclusive assessment. CT angiography showed cTBAD with an insufficient proximal landing zone in Ishimaru Zone 2. A staged hybrid strategy was used that combined a carotid-subclavian bypass with thoracic endovascular aortic repair using off-the-shelf devices. This method restored blood flow to the limbs, resulted in complete thoracic false-lumen thrombosis without endoleak, and led to a smooth recovery with good functional status. CONCLUSION: This case demonstrates that hybrid arch debranching and TEVAR can offer a safe and long-lasting solution for complex cTBAD in resource-constrained rural centers, contingent upon meticulous planning and conventional imaging. It emphasizes the necessity for prompt identification of atypical chest pain, timely referral, and practical modification of endovascular techniques to accommodate local limitations to avert late malperfusion.