CONGRESS ABSTRACT

Case Report A 72-year-old male patient presented with chest pain. His medical history included COPD, atrial fibrillation, hypertension,  NIDDM, and prior CABG. Clinical Findings CT angiography revealed a large pseudoaneurysm at the origin of the brachiocephalic artery involving the distal ascending aorta and the proximal segment of the aortic arch. The pseudoaneurysm measured 44 mm in maximum diameter and was associated with a significant perilesional hematoma occupying the superior mediastinum in the right paratracheal region. Coronary angiography confirmed graft patency. Preoperative Assessment The risk of conventional cardiac surgery was deemed extremely high (ASA IV; EuroSCORE II = 30.8%; STS score = 8.1%). Endovascular exclusion of the lesion in a single-stage approach was not feasible due to inadequate anchoring zones. A two-stage hybrid strategy was chosen: rerouting of the supra-aortic trunks followed by implantation of a NEXUS endograft, which consists of a main module for the aortic arch, which includes a branch for the brachiocephalic trunk, and an ascending module that connects the main module to the ascending aorta.   Stage 1: Surgical Procedure A bypass graft using an 8-mm Dacron tube was performed between the right common carotid artery, the left common carotid artery (side-to-side anastomosis), and the left subclavian artery (end-to-side anastomosis). Stage 2: Endovascular Procedure A filter system was pre-emptively placed in the graft to prevent neurometabolic complications. Under fluoroscopic guidance and ventricular pacing, the main NEXUS module was advanced along a brachiocephalic guidewire using a "cableway" technique from the axillary artery. Its proximal end was deployed within the brachiocephalic trunk (40 mm). In comparison, the distal end was anchored in the descending thoracic aorta at the level of the isthmus (total coverage length = 180 mm). Subsequently, the ascending module was advanced via the femoral introducer sheath. Postoperative Course The patient was discharged on the fourth postoperative day asymptomatic. A follow-up CT angiography confirmed the debranching graft's patency, stable positioning of endograft components, and absence of endoleak. Conclusion Advances in material technology and operator expertise enable fully endovascular treatment of aortic arch pathologies in patients with high or prohibitive surgical risk.