When History Returns: Hybrid Management of Syphilitic Aortitis Causing Severe Aortic Arch Branch Stenosis and Cerebral Hypoperfusion

Introduction: Cardiovascular manifestations of tertiary syphilis are rare in the antibiotic era, but important to consider in atypical vascular findings. These manifestations typically appear several years after the primary infection and may lead to structural damage in the cardiovascular system, requiring surgical intervention despite appropriate antibiotic therapy. Report: This case describes a rare manifestation of cardiovascular syphilis in a 46 year old woman presenting with dizziness, pre-syncope, and syncope consistent with global cerebral ischaemia. Extensive evaluation revealed syphilitic aortitis with severe stenosis and or occlusion of all the major aortic arch branches. The patient was managed with antibiotic therapy in combination with surgical revascularisation. Both endovascular and open surgical approaches were used to restore blood flow to the left common carotid, left vertebral, and left subclavian arteries. This intervention improved cerebral perfusion and resolved the patient’s symptoms. At two years, the carotid stent was patent, while the carotid subclavian bypass was occluded. The patient remained free from cerebral ischaemic symptoms but reported bilateral arm claudication. Conclusion: Tertiary syphilis should be considered as a differential diagnosis when atypical arterial disease is encountered. Hybrid revascularisation may provide an effective, less invasive treatment strategy.