Mega-aorta with aberrant right subclavian artery: use of a novel hybrid technique

A novel approach to the management of aortic arch aneurysm with an aberrant right subclavian artery (ARSA) is described. Construction of a Dacron graft with side arms adapted to the patient's arch anatomy allows for antegrade cerebral perfusion during circulatory arrest and revascularisation of the arch vessels. A long elephant-trunk graft is lowered into the descending aorta using a snare introduced from the femoral artery. Descending aortic stenting can be performed concomitantly or later. Advantages include antegrade cerebral perfusion during arch repair, diminished extent of stenting due to the long elephant trunk, type II endoleak prevention by ARSA ligation and preservation of antegrade flow in the right vertebral artery.