Emergent Repair of a Complex Dissecting Aneurysm in the Thoracic Aorta

Endovascular treatment of complex thoracic pathologic conditions involving the aortic arch can often be appropriate and safe; however, minimally invasive procedures are not always feasible, especially in emergent cases. We report the case of a 78-year-old woman who emergently presented in hemorrhagic shock with a ruptured chronic dissecting aneurysm that involved the aortic arch. Eight years earlier, she had undergone aortic valve replacement and plication of the ascending aorta, which was complicated a day later by Stanford type B dissection, malperfusion, and ischemia that required an axillobifemoral bypass. At the current admission, we successfully treated her surgically through a left thoracotomy, using moderate hypothermic extracorporeal circulation and advanced organ-protection methods. We discuss the surgical indications and our operative strategy in relation to open surgical repair versus endovascular treatment in patients with complex conditions.Key words: Aneurysm, dissecting/radiography/surgery; aortic aneurysm, thoracic/radiography/surgery; aortic diseases/surgery; aortic rupture/surgery; treatment outcome; vascular surgical proceduresPathologic involvement of the aortic arch and the presence of dissection are 2 major issues in descending thoracic aortic repair, particularly in emergent settings of aneurysmal rupture. A patient''s comorbidities and older age may contraindicate deep hypothermic circulatory arrest; however, a thoracoabdominal dissection could lead to malperfusion if left-side heart bypass is considered for organ protection. Endovascular or hybrid surgery is a less invasive approach in complex cases; however, a good aneurysmal neck and adequate vascular access for the device are mandatory for technical success. We present the case of an elderly woman with comorbidities who required emergent repair of a complex dissecting thoracic aneurysm.