Case presentation
A patient in his 80s presented with a severe transfixing chest pain
which started suddenly while walking to the bathroom. His past medical
history included hypertension, atrial fibrillation, multilevel
peripheral arterial disease, open abdominal aortic aneurysm repair and
mild neurocognitive disorder. On physical examination, he was
hemodynamically stable and well perfused. His electrocardiogram was
unremarkable and his troponins were negative. A chest x-ray showed a
widened mediastinum and a mild left pleural effusion. A computed
tomography angiography revealed a pseudoaneurysm along the inferior
posterior wall of the aortic isthmus and measuring 74x88 mm (Fig.1). He
was immediately started on a labetolol infusion for blood pressure and
heart rate control. Given his frailty, comorbidities and increased risk
of bleeding from the use of apixaban, he was deemed too high-risk for
conventional total arch replacement. On the other hand, there was no
off-the-shelf branched stent grafts available and the acuity of the
presentation didn’t allow the use of a custom-made stent graft. A
multidisciplinary discussion involving the family concluded that a
hybrid off-pump approach should be attempted.