Complex Endovascular Management of a Giant Ruptured Aortic Arch and Descending Aneurysm Following Prior Endovascular Aneurysm Repair: A Case Report

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BACKGROUND This case report presents a groundbreaking approach to treating a giant ruptured aortic arch aneurysm in a patient who previously underwent endovascular aneurysm repair (EVAR). CASE REPORT A 66-year-old man was admitted for surgical intervention due to a ruptured aortic arch aneurysm. He presented with shock, hypotension, hemorrhage into the left pleura, and chest and abdominal pain. He had a history of EVAR 10 years prior. An urgent computed tomography angiography revealed a ruptured aortic arch aneurysm, 12 cm in diameter, with a descending thoracic aorta segment with features of rupture to the pleura, displacing the trachea, and compressing the left main bronchus. The diameter of the ascending aorta was within normal limits and the abdominal aorta was slightly dilated, with the right stent-graft leg ending in a right common iliac artery aneurysm. As a result, the patient was deemed ineligible for cardiac surgery and qualified for an endovascular procedure, which involved a triple-branched total endovascular arch repair, showcasing significant technical innovation. A right-sided iliofemoral graft was performed with a vascular prosthesis. Completion angiography demonstrated patent branches and successful exclusion of the aneurysm. Despite intensive care following the operation, growing multiorgan failure associated with the patient's multiple concomitant diseases contributed to his eventual death. CONCLUSIONS The case highlights the feasibility and effectiveness of this advanced technique in managing complex aortic pathologies, even in patients with prior interventions. The importance of this method as a viable option for complicated cases is emphasized, offering insights into potential improvements in patient outcomes.

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