Rare Aortic Arch Aneurysm Emergency Managed With Hybrid Precision
A complex, life-threatening post-subclavian aortic arch aneurysm with thrombus and coronary artery disease was successfully treated at Tulip Mediworld Superspeciality Hospital using a hybrid surgical and endovascular approach, restoring vascular stability and preventing catastrophic rupture.
The Challenge: Initial Presentation
The patient presented with progressive respiratory symptoms, voice hoarseness, generalized weakness, and reduced appetite. Advanced evaluation revealed a large saccular aneurysm of the aortic arch exerting significant pressure on adjacent vascular and pulmonary structures, posing an imminent risk of rupture and sudden death.
Given the critical anatomical location and compressive effects of the aneurysm, the clinical scenario represented a life-threatening vascular emergency. The presence of airway compromise, recurrent laryngeal nerve involvement, and haemodynamic instability necessitated urgent decision-making.
A multidisciplinary heart–vascular team promptly formulated a definitive management strategy, balancing the risks of intervention against the catastrophic consequences of non-treatment. Immediate surgical intervention was deemed essential to prevent fatal rupture and irreversible end-organ damage.
The Challenge: Initial Presentation
- Large (57 × 53 mm) saccular aneurysm arising from the lateral aspect of the aortic arch at the level of the subclavian artery origin
- Aneurysm indenting the left pulmonary artery
- Large peripheral thrombus with residual lumen measuring approximately 19 × 38.8 mm
- Wide aneurysmal neck measuring 29 mm
- Mild left main coronary artery disease with moderate triple vessel disease (Coronary angiography: 29/10/2025)
- Type 2 Diabetes Mellitus on oral hypoglycaemic agents
- History of Pott’s spine with spinal fixation (2023)
Diagnosis:
Advanced CT angiography, echocardiography, and coronary evaluation enabled:
- Accurate anatomical mapping of the aneurysm
- Risk stratification in the presence of coronary disease
- Meticulous planning of a hybrid vascular strategy
- Reduction of perioperative and neurological risk
Early diagnosis proved decisive in preventing fatal complications.
The Solution: Hybrid Intervention & Treatment
Procedure Done
CTVS – Operating Theatre
- Right Common Carotid → Left Common Carotid artery bypass using an 8 mm wire-reinforced PTFE graft (JOTEC)
- Left Common Carotid → Left Subclavian artery bypass using an 8 mm wire-reinforced PTFE graft (JOTEC)
Cath Lab – Endovascular Repair
- Deployment of a 34 × 28 × 160 mm stent graft from the distal aortic arch to the descending thoracic aorta
The procedure was performed under the leadership of Dr. Apurba Kumar Sarma, supported by a multidisciplinary cardiac, vascular, and anaesthesia team.
The Outcome: Recovery & Stabilisation
A Life Secured. A Vascular Catastrophe Averted.
- Successful exclusion of the aneurysm
- Restored cerebral and upper limb perfusion
- Stable coronary and cardiac function
- No neurological deficits or graft-related complications
- Uneventful recovery with haemodynamic stability
Follow-up imaging confirmed a well-positioned stent graft, complete thrombosis of the aneurysm sac, and patent bypass grafts without evidence of endoleak or perigraft collection.
