Ruptured aortic arch aneurysm: transposition of aortic arch branches after insertion of thoracic endovascular stent with extra-anatomic brain perfusion.

Conventional surgical treatment of a ruptured aortic arch aneurysm is a challenging approach with a high rate of adverse outcomes. The midsternotomy can be complicated by total aortic disruption with often fatal massive hemorrhage. A preliminary cardiopulmonary bypass with peripheral cannulation and cooling is often preferred. Endovascular stents have been used in patients with thoraco-abdominal aneurysms, with good results. Its lone utilization for rupture of aortic arch aneurysm is not feasible because of the unavoidable occlusion of cerebral vessels' origins. A previous aorto-bicarotid bypass is mandatory and it requires the midsternotomy. Hence, we developed a combined technique. We performed a hybrid approach in a 74-year-old patient, affected by an aortic arch aneurysm, ruptured in its antero-inferior portion. First we ensured brain perfusion with a temporary surgical extra-anatomic (femoral-bicarotid) bypass. Then an endovascular stent graft was expanded from the distal portion of ascending aorta to the proximal one of the thoracic aorta, thus excluding the ruptured portion of the aortic arch. Then the patient underwent the definitive aorto-carotid bypass. This specific combined technique allows the complete treatment of a ruptured arch aneurysm, lowering the risks connected with sternothomic approach, mainly with previous cardiopulmonary bypass and deep hypothermic circulatory arrest.