Two-Stage Hybrid Repair of a Large Aortic Arch Aneurysm: Supra-Aortic Debranching Followed by Thoracic Endovascular Aortic Repair

Background Aortic arch aneurysms remain challenging to treat because of their proximity to the supra-aortic branches and the need to preserve cerebral perfusion. Conventional open total arch replacement may be associated with considerable perioperative risk in selected patients. Hybrid repair, consisting of surgical supra-aortic debranching followed by thoracic endovascular aortic repair (TEVAR), may provide an alternative treatment strategy when adequate landing zones cannot be achieved with standard TEVAR alone. Case Presentation A 61-year-old man presented with chest pain radiating to the back. Computed tomography angiography demonstrated a symptomatic saccular aortic arch aneurysm extending into the descending thoracic aorta, with a maximal diameter of 70.1 mm and involvement of the origins of the supra-aortic vessels. Because of hypertension, diabetes mellitus, and active smoking, the patient was considered to have an increased risk for conventional open total arch replacement. He had no history of previous cardiac, thoracic, or vascular surgery. A two-stage hybrid strategy was selected. First, supra-aortic debranching was performed through a median sternotomy using Dacron grafts to revascularize the brachiocephalic trunk, left common carotid artery, and left subclavian artery. Four weeks later, after computed tomography angiography confirmed graft patency, TEVAR was performed using the surgically created proximal landing zone. The postoperative course was uneventful. One-month follow-up imaging demonstrated patent debranching grafts, stable endograft position, complete aneurysm exclusion, and no detectable endoleak. Conclusion Two-stage hybrid repair may be a feasible option for selected patients with complex aortic arch anatomy who are considered to be at increased risk for conventional open repair. This case demonstrates a favorable early clinical and radiological outcome. Longer follow-up is required to assess long-term durability.