The optimal surgical management for extensive aortic arch aneurysms involving the aortic arch and descending aorta has not been clearly established. Currently, proposed management includes single-stage open surgery [3], two-stage TAR with TEVAR, and hybrid endovascular repair [1]. Single-stage open surgery requires the exposure of the entire thoracic aorta, such as in a median sternotomy with left thoracotomy. The extensive surgery is invasive, and requires longer CPB time and longer cerebral protection time. These factors increase the risk of serious complications. Patients with multiple comorbidities may experience significant morbidity and mortality from both neurologic and cardiovascular complications [4].
The two-stage TAR with TEVAR can avoid extensive exposure, but it requires the replacement of the aortic arch and the anastomosis of supra-aortic vessels. The distal anastomosis on the aortic arch is deep and must be conducted on diseased aortic wall. This is a technical challenge and increases the risk of unmanageable bleeding. The replacement of the aortic arch also increases the number of anastomoses. The branched graft may be twisted and occluded [5].
Hybrid endovascular repair, including supra-aortic vessel transposition combined with TEVAR, has emerged as an alternative, to reduce the complications of open surgical repair. However, it is still associated with multiple complications. It has been reported that the incidences of stroke and endoleak were 9.7–14.3% and 19–24.5%, respectively [6, 7]. The long-term outcome of this hybrid treatment has not been reported.
Compared with the above techniques, our approach has avoided the aortic arch distal anastomosis. We repaired the aortic arch from inside the aortic arch, which simplifies the surgical procedures and avoids unmanageable bleeding. Unlike hybrid endovascular repair, our approach has securely sutured the stent-graft with normal tissue of the aortic arch. As a result, our approach avoids endoleak and stent-graft displacement. Moreover, the stent-graft can provides enough landing zone for TEVAR, ensuring coverage of the entire aneurysm. The patient fully recovered without any complications.