Authors

• Petra Grubić Rotkvić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-2587-1932
• Tomislav Krčmar — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0003-4689-1673
• Nermin Lojo — University Hospital Centre Zagreb, Zagreb, Croatia
• Kristina Marić Bešić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-4004-7271
• Andrea Crkvenac Gregorek — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-7790-1347
• Anica Milinković — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-3456-9540
• Majda Vrkić Kirhmajer — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-1340-1917

Keywords

aortic rupture, aortic arch debranching, thoracic endovascular aortic repair

DOI

Full Text

**Introduction**: A ruptured aortic arch aneurysm is a life-threatening condition associated with extremely high rates of mortality. If diagnosed before rupture, it can be prevented by elective repair, but in an acute setting, the fatal outcome is often unavoidable. (1) **Case report**: We present the case of a 73-year-old male patient with a history of chronic obstructive pulmonary disease (COPD), nicotinism, arterial hypertension, and atrial fibrillation on anticoagulant therapy. He was referred to our center for operative assessment after being diagnosed with contained polytopic aortic arch rupture extending between the innominate to the left subclavian artery (LSA) (**Figure 1**). Additionally, there was a dissection of the proximal LSA and a moderate hemorrhagic pericardial effusion without signs of tamponade. Upon arrival, the patient was hemodynamically stable complaining of chest pain and hoarseness. Due to the technically challenging lesion location, prolonged cardiac surgery operative duration, extended circulatory time arrest, and the unavailability of custom-made prosthesis in acute setting, the multidisciplinary team determined that the patient was a candidate for a hybrid approach using both open surgical extra anatomic aortic arch debranching and Thoracic Endovascular Aortic Repair (TEVAR). (2, 3) Since TEVAR needed to be extended into zone 1 of the aortic arch, revascularization of the left carotid artery was necessary to prevent neurovascular compromise. A carotid-carotid crossover bypass with revascularization of LSA along with TEVAR placement extending from zone 1 to the descending aorta were successfully performed. The patient recovered in the intensive care unit and was extubated the following day. A subsequent CT angiogram showed a good position of the endograft without endoleak and with patent bypasses (**Figure 2**). He was transferred to the cardiology ward where he exhibited an exacerbation of COPD that was successfully treated with standard pharmacological and breathing therapy. Two months after discharge, he attended an outpatient visit in a very good functional status (**Figure 3**). FIGURE 1. Contrast enhanced CT angiography showing aortic arch rupture (A), hemorrhagic pericardial effusion (B), 3D reconstruction of the aorta (C). FIGURE 2. CT angiography showing patent carotid-carotid bypass and carotid-subclavian bypass (A), and 3D reconstruction showing bypasses with TEVAR (B). FIGURE 3. Healed postoperative wounds after aortic arch debranching. **Conclusion**: This case demonstrates a successful hybrid, less invasive approach in an acute life-threatening setting for a condition that is conventionally treated with complex elephant trunk procedure.

Literature

1. Johansson G, Markström U, Swedenborg J. Ruptured thoracic aortic aneurysms: a study of incidence and mortality rates. J Vasc Surg. 1995 June;21(6):985–8. https://doi.org/10.1016/S0741-5214(95)70227-X
2. Gilani A, Schachner B, Wood E, Khawaja Z, Imielski B. Total aortic arch debranching with antegrade Thoracic Endovascular Aortic Repair (TEVAR) in acute non-A non-B aortic dissection. J Cardiothorac Surg. 2024 June 28;19(1):401. https://doi.org/10.1186/s13019-024-02917-2
3. Moulakakis KG, Mylonas SN, Markatis F, Kotsis T, Kakisis J, Liapis CD. A systematic review and meta-analysis of hybrid aortic arch replacement. Ann Cardiothorac Surg. 2013 May;2(3):247–60. https://doi.org/10.3978/j.issn.2225-319x.2013.05.06