From complexity to cure: hybrid management of a giant Innominate artery pseudoaneurysm

A 72-year-old man presented with a six-month history of intermittent fever and elevated inflammatory markers (C-reactive protein 13.6 mg/L; erythrocyte sedimentation rate 60 mm/h). He denied any history of trauma, infection, or prior cardiothoracic surgery. Contrast-enhanced computed tomography angiography revealed a 46 × 36 mm pseudoaneurysm at the terminal segment of the innominate artery, containing mural thrombus and communicating with the parent vessel via a 5-mm neck (Figure 1(A-C); Supplementary Video 1). Although infective work-up was declined by the patient, the clinical and imaging features raised strong suspicion for an infectious aetiology. A hybrid repair was therefore performed: first, a right carotid-subclavian bypass using an 8 mm GORE-TEX graft, followed by endovascular exclusion of the pseudoaneurysm with a 12 × 100 mm GORE PLC covered stent. Adjunctive embolisation of the residual sac was achieved using detachable coils and a 14-16-mm Amplatzer vascular plug (Figure 1(D); Supplementary Video 2). The patient recovered uneventfully, completed a two-week course of oral cefuroxime axetil, and remained afebrile at three-month follow-up with complete resolution of symptoms. Infectious pseudoaneurysms of the innominate artery are exceedingly rare, typically arising post-trauma or post-surgery [1,2]. This case presents a rare instance of an innominate artery pseudoaneurysm manifesting with systemic inflammation in the absence of preceding trauma or iatrogenic injury. The adopted hybrid strategy-combining carotid-subclavian bypass, endovascular exclusion, and adjunctive embolisation-represent a less invasive yet effective option for managing such complex supra-aortic lesions, potentially offering durable exclusion while maintaining cerebral perfusion. The uneventful recovery and symptom resolution at three months support hybrid repair as a viable strategy in select cases, though long-term surveillance remains essential given the risk of late graft infection or recurrence.