Reversed sequence arch debranching for treatment of a ruptured juxta-innominate artery saccular aneurysm

Purpose: To describe a hybrid approach for the treatment of a ruptured juxta-innominate artery saccular aneurysm. Case report: A 68-year-old smoker male with poor exercise tolerance sustained a contained ruptured saccular aneurysm at the origin of the innominate artery. Although under the femoral-axillary bypass to allow direct brain perfusion, a 36 × 110 mm thoracic endograft was successfully deployed with total coverage of the distal ascending and aortic arch. A sternotomy was performed and an aorto-innominate and left common carotid artery bypass was done. At 1-month follow-up, a type 2 endoleak at the innominate artery stump was noted and successfully treated with coil embolization. The patient remains neurologically intact 1 year after the surgery. Conclusion: Juxta-innominate artery saccular aneurysms are rare. A hybrid open-endovascular repair using a reversed sequence arch debranching after endovascular repair is feasible and may be an alternative to deep hypothermic circulatory arrest particularly in frail patients.