Aortic arch aneurysm is a rare condition but carries a high risk of rupture. Previous reports that we have identified in English literature included conventional surgical repair, hybrid surgery and embolization of an aortic arch aneurysm with detachable coils [1–5]. Conventional surgical intervention requires a thoracotomy, cardiopulmonary bypass, hypothermic circulatory arrest and aortic cross-clamping, thus remains a surgical challenge with a high rate of mortality (7-17%) and neurologic complication (4-12%) [1, 2, 6]. We report one case of aortic arch aneurysm combined with aortic arch coarctation and left internal carotid artery (LICA) aneurysm, which is extremely rare. Hybrid procedure was performed successfully, which appears to be a promising minimally invasive approach to manage this rare entity.

Standard treatment for aortic arch aneurysm is open surgery, due to its good long term results [7, 8]. But surgical repair of the aorta requires thoracotomy, cardiopulmonary bypass, hypothermic circulatory arrest, aortic crossclamping and systemic heparinization. Conventional surgical repair for aortic arch pathology carries a high mortality and morbidity, with a particularly significant incidence of neurologic injury [1, 6, 9]. Therefore they were gradually replaced by endovascular treatment due to the complexity of the surgery, surgical trauma and high associated mortality rate. Endovascular treatment is less invasive and is associated with lower morbidity and mortality [3–5]. Since endovascular procedure does not require thoracotomy, circulatory assistance is not necessary and significant haemorrhages are less likely. What is more, endovascular intervention does not need aortic cross-clamping as such the risk of cerebral, spinal cord and visceral ischemia was decreased. Due to the lower morbidity and mortality rates, thoracic endovascular aortic repair (TEVAR) is considered an acceptable alternative to open surgical repair for patients with various types of aortic diseases. With the successful experience including ours, using of a fenestrated or branched stent graft and double chimneys, which is able to preserve perfusion of the supra-aortic arch vessels, could be one of the alternative approaches [10, 11]. However, simple application of TEVAR to treat aortic arch aneurysm combined with aortic arch coarctation and LICA aneurysm such as our case may cause cerebral ischemia and infarction. In this case, the aortic arch aneurysm located at the greater curvature, combining with aortic arch coarctation and LICA aneurysm, and the LSA was arising from the aortic arch aneurysm. Endovascular therapy could not repair all the lesions; however, conventional open surgery would be complicated and have high associated mortality rate, so hybrid procedure was a good alternative approach. Because of the dominant right vertebral artery, we could occlude the LSA but without causing cerebral ischemia or cerebral infarction. But if the patient presents with left arm ischemia, a subclavian to subclavian artery or axillary to axillary artery graft bypass could be performed. Although there was a very mild stenosis of LICA and aortic arch at 8-month postoperatively, but the patient does well without any complaints and complications. Our successful experience in this patient suggests that the combined endovascular and surgical treatment seems to be a valuable therapeutic alternative when treating this type of aortic arch lesion with advantages of performing less aggressive surgery and avoiding aortic cross-clamping, circulatory assistance and high dose heparinization. But long-term follow-up of a larger number of patients is needed to assess and confirm these favorite results in order to promote these approaches.

Our case suggests that hybrid procedure in treating aortic arch aneurysm combined with aortic arch coarctation and LICA aneurysm is a better choice. The use of combined open and endovascular repair in the treatment of aortic arch pathology appears safe and effective at perioperative, postoperative and early midterm follow-up and offers several advantages over conventional surgical repair, including the potential to offer therapy to patients who are not candidates for open repair.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.