Hybrid Repair of Ruptured Arch Aneurysm Without Sternotomy Through an Unusual Extraanatomic Bypass Chung-Lin Tsai, MD, Chih-Chun Yang, MD, Takuya Fujikawa,

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Hybrid Repair of Ruptured Arch Aneurysm Without Sternotomy Through an Unusual Extraanatomic Bypass Chung-Lin Tsai, MD, Chih-Chun Yang, MD, Takuya Fujikawa, MD, Shih-Rong Hsieh, MD, PhD The Annals of Thoracic Surgery Volume 103, Issue 2, Pages e209-e211 (February 2017) DOI: 10.1016/j.athoracsur.2016.08.039 Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) Sagittal view. (B) Coronal view. Preoperative computed tomographic aortographic views showing a 7-cm aortic arch in B (white arrow), a 6-cm descending aortic aneurysm with anterior rupture in A (black arrow), and a mediastinal hematoma. The Annals of Thoracic Surgery 2017 103, e209-e211DOI: (10.1016/j.athoracsur.2016.08.039) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) Anastomosis of one 24-mm × 12-mm × 12-mm bifurcated gelatin-sealed polyester vascular graft to the abdominal aortic true lumen. (B) Then, anastomosis of two 12-mm polyester vascular grafts to each of the previous 12-mm limbs of the bifurcated graft and extended to the neck through a subcutaneous tunnel created through the chest wall; insertion of a 16-mm Endurant II endoprosthesis into both 12-mm vascular grafts for reinforcement. (C) Anastomosis of another two bifurcated 16-mm × 8-mm × 8-mm vascular grafts to both carotid arteries and subclavian arteries. (D) Finally, implantation of Gore TAG endoprostheses measuring 37 mm × 20 cm, 37 mm × 15 cm, and 31 mm × 10 cm within the previous replaced ascending aortic graft. The Annals of Thoracic Surgery 2017 103, e209-e211DOI: (10.1016/j.athoracsur.2016.08.039) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Computed tomographic angiogram 3 months after the procedure, showing effective exclusion of the ruptured arch aneurysm and patency of all bypass grafts. The Annals of Thoracic Surgery 2017 103, e209-e211DOI: (10.1016/j.athoracsur.2016.08.039) Copyright © 2017 The Society of Thoracic Surgeons Terms and Conditions