One size does not fit all – Staged hybrid approach of a challenging aortic arch aneurysm using a double-branch custom-made device

Background: The anatomical complexity of the aortic arch poses significant challenges to its repair, particularly in high-risk patients. The introduction of branched endografts, specifically designed to overcome these challenges, has revolutionized this field as demonstrated in the present case-report. Report: A 60-year-old male, with a prior history of smoking and neurosyphilis, was referenced to our outpatient clinic due to a CT finding of a 66mm aortic arch aneurysm with complex anatomical features, including a short brachiocephalic trunk and narrow iliac arteries. Thus, a staged hybrid approach was meticulously planned. The patient was initially submitted to a left carotid-subclavian bypass, followed by a right subclavian-carotid bypass. Later, an endoconduit was constructed using two GORE-Viabahn® stent grafts (11x100mm), deployed in the left common and external iliac arteries, facilitating subsequent TEVAR. Finally, the aneurysm was excluded using a custom-made Terumo-Relay® double inner-branched endograft (46x32x270mm) deployed in zone 0, with two inner branches for the brachiocephalic trunk (BCT)/right subclavian artery (RSA) and left common carotid artery (LCCA). The inner branches were catheterized via trans-carotid (left) and trans-axillary (right) accesses. An iliac extension GORE-Excluder® (16x12x100mm) to the BCT/RSA and a GORE-Viabahn® stent graft (7x75mm) to the LCCA were deployed. An additional extension endograft (34x30x150mm) was deployed to complete distal exclusion. The left subclavian artery was subsequently occluded using a vascular plug. Postoperatively, the patient experienced a minor posterior circulation stroke, with full recovery within two weeks. Six-month follow-up imaging showed patency of the endografts with complete exclusion of the aneurysm and no evidence of endoleaks. The patient remained asymptomatic, with no further vascular or neurological events. Conclusion: This case highlights the feasibility of a staged hybrid approach for complex aortic arch aneurysms in patients with challenging anatomy. The use of a custom-made endograft and careful preoperative planning proved critical to the success of the procedure.