Penetrating atherosclerotic aortic ulcer with pseudoaneurysm: Role of hybrid procedure with d-TEVAR

We present a case of penetrating atherosclerotic aortic ulcer with pseudoaneurysm which was managed by a hybrid partial debranching thoracic endovascular aneurysm repair (d-TEVAR) procedure. A 68-year-old professional singer with multiple comorbidities presented with mid-chest pain radiating to the back for the past 2 months. Computed tomography aortogram revealed a penetrating atherosclerotic ulcer near the summit of the left subclavian artery (LSA) at the distal aortic arch. In view of the high risk of an open-heart surgery, TEVAR procedure with partial debranching of the aortic arch vessel was proposed. As the aneurysm was close to the origin of the LSA, an adequate proximal landing zone was not available. Hence, a bypass from the left common carotid artery to the LSA was done. Following this, an endovascular procedure was performed and the stent graft was placed covering the origin of the LSA. Check aortograms after the procedure revealed patent stent and complete obliteration of the pseudoaneurysm. There was no endoleak noted and the left carotid to subclavian artery bypass was functioning well. The postoperative period was uneventful. Follow-up over a 6-month period was satisfactory. The key elements of a successful thoracic endovascular aneurysm repair are appropriate patient selection, thorough planning, and careful procedural execution. This case demonstrates that a hybrid procedure with partial debranching and thoracic endovascular repair of penetrating aortic ulcers is a safe and less-invasive alternative for elderly, high-risk patients.