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.