A challenging case involving a patient with both an aortic arch aneurysm and a blocked subclavian artery was successfully treated through a sophisticated staged surgical approach. This intervention included aortic arch de-branching and thoracic endovascular aortic repair (TEVAR), demonstrating the critical role of multidisciplinary collaboration and advanced cardiovascular techniques in managing complex vascular diseases.

A challenging case involving a patient with both an aortic arch aneurysm and a blocked subclavian artery was successfully treated through a sophisticated staged surgical approach. This intervention included aortic arch de-branching and thoracic endovascular aortic repair (TEVAR), demonstrating the critical role of multidisciplinary collaboration and advanced cardiovascular techniques in managing complex vascular diseases.

A challenging case involving a patient with both an aortic arch aneurysm and a blocked subclavian artery was successfully treated through a sophisticated staged surgical approach. This intervention included aortic arch de-branching and thoracic endovascular aortic repair (TEVAR), demonstrating the critical role of multidisciplinary collaboration and advanced cardiovascular techniques in managing complex vascular diseases.

For most people, a blocked artery may sound like a problem confined to a limb. An aneurysm may sound like a separate concern. But when both occur in one of the body’s most vital arterial crossroads—the aortic arch—the challenge becomes considerably more complex.

The patient’s successful recovery underscores a larger lesson in modern cardiovascular medicine: when disease involves a critical structure such as the aortic arch, there may be no single straightforward solution.

That was the situation faced by a 56-year-old man who was diagnosed with a saccular aneurysmal dilatation of the arch of the aorta (a localised pouch-like bulge on the curved upper part of the main artery carrying blood from the heart). He was also diagnosed with a short-segment total occlusion of the ostio-proximal left subclavian artery—complete blockage, spanning a small stretch, at the very beginning and first part of the subclavian artery that supplies blood to the arm, neck and back of the brain. He had been experiencing pain during exercise in his left arm for around two weeks. His medical history also included treated prostate cancer, diabetes and hypertension.

An aneurysm of the aortic arch presents a particularly demanding surgical problem because the arch is not simply a section of the body’s largest blood vessel. It is also the point from which major arteries branch off to supply the brain and the upper limbs.

Before intervention, the medical team undertook detailed cardiac and neurological assessment. Coronary angiography showed no flow-limiting coronary artery disease. Importantly, because the planned procedure involved the vessels supplying the brain, neurology consultation was obtained. Cerebral digital subtraction angiography and a balloon occlusion test demonstrated that the patient tolerated temporary occlusion of the left internal carotid artery without clinical symptoms of left hemispheric dysfunction.

The team recognised that the intervention carried significant risks, including stroke and worsening renal function. After discussing these risks with the patient’s relatives, a staged approach was chosen.

The first stage, performed on October 15, 2025, involved aortic arch de-branching. Through a median sternotomy, surgeons created alternative pathways for blood to reach the major branches of the aortic arch. A Dacron Y-graft was connected to the ascending aorta and then to the innominate and left carotid arteries. A separate graft was connected to the left axillary artery to improve blood flow to the left upper limb. Throughout the procedure, cerebral circulation was monitored using real-time transcranial Doppler.

The following day came the second stage: thoracic endovascular aortic repair (TEVAR), a minimally invasive technique in which a stent graft is introduced through an artery—often through the femoral artery—and positioned inside the diseased section of the thoracic aorta. The graft reinforces the weakened vessel and redirects blood flow through the stented channel. In this case, through the femoral arteries, a 40×36×150cm thoracic stent graft was positioned from the ascending to the descending thoracic aorta. The final angiogram showed good apposition of the stent graft with no endoleak—a successful immediate technical result.

The operation was only one part of the story. The postoperative period required equally careful monitoring. Followup MRI of the brain and MR angiography showed no significant narrowing in the major cervical or intracranial arteries. By discharge, he was stable and ambulant, with palpable pulses in all four limbs and a clean surgical wound.

For the treating team, the case demonstrates how increasingly complex aortic conditions can demand the combined expertise of cardiovascular surgery, cardiac anaesthesia and critical care, cardiology, neurology and nephrology.

The patient’s successful recovery underscores a larger lesson in modern cardiovascular medicine: when disease involves a critical structure such as the aortic arch, there may be no single straightforward solution. Careful imaging, neurological assessment, surgical reconstruction, endovascular technology and intensive postoperative monitoring can come together to create a treatment strategy tailored to the patient’s anatomy and risks.

The author is chief and senior consultant, cardiovascular thoracic surgery, Baby Memorial Hospital, Kozhikode.

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