Debranching Thoracic Endovascular Aortic Repair for Kommerell's Diverticulum with Right-Sided Aortic Arch / 日本心臓血管外科学会雑誌

We report a case of debranching thoracic endovascular aortic repair for Kommerell's diverticulum with right-sided aortic arch in 78-year-old women. The computed tomography (CT) demonstrated Kommerell's diverticulum with a right-sided aortic arch and the trachea and esophagus were compressed by the diverticulum. The diverticulum had a maximum diameter of 32 mm, and surgical intervention was chosen because of the aneurysmal change and the possibility of rupture. We performed endovascular aortic repair for Kommerell's diverticulum with a right-sided aortic arch because of low lung function and low frailty. The patient was discharged on the 21st postoperative day. There was no evidence of aortic event during 2 years follow up.

Surgical Strategy for Protecting Major Branch Arteries during Thoracic Endovascular Aortic Repair for Shaggy Descending Aortic Aneurysms / 日本心臓血管外科学会雑誌

Surgery for a shaggy aortic aneurysm requires a meticulous strategy to prevent embolic complications since the complications are associated with longer length of hospital stay and higher mortality. However, until now, there are no established treatment options to prevent embolic complications. We report a case of a 75-year-old man with a descending aortic aneurysm and a shaggy aorta who underwent thoracic endovascular aortic repair (TEVAR) with major branch artery protection. During the procedure, we placed balloon catheters in the left subclavian and left common iliac arteries, a filter device in the superior mesenteric artery, and a sheath at the ostium of the right common iliac artery. The patient did not develop embolic or other complications and was discharged on the eighth postoperative day. Our strategy of using the balloon occlusion technique and filter placement at the major vessels effectively prevented embolic complications during TEVAR for a shaggy aorta.

Thoracic Endovascular Aortic Repair for Chronic Aortic Dissection with an Isolated Left Vertebral Artery / 日本心臓血管外科学会雑誌

Thoracic endovascular aortic repair (TEVAR) is valuable in the treatment of type B aortic dissection. An isolated left vertebral artery (ILVA) is a common anomaly of the aortic arch. The ILVA is covered during TEVAR in specific cases; however, whether the ILVA should be reconstructed in all cases remains controversial. We report a case of TEVAR performed for chronic aortic dissection in a patient with an ILVA. A 57-year-old woman with an ILVA had a type B acute aortic dissection one year prior to presentation and underwent TEVAR owing to dilation of an ulcer-like projection. We performed ILVA-left common carotid artery (LCCA) anastomosis and LCCA-left axillary artery bypass prior to TEVAR using our usual procedure. The postoperative course was favorable without any major complication. ILVA reconstruction may reduce the incidence of postoperative stroke and spinal cord injury. Usually, an ILVA is easily accessible through the supraclavicular approach, and the anatomical position of the vessel facilitates ILVA-LCCA anastomosis. ILVA reconstruction requires additional features and further consideration.

Two Cases of Successful Treatment of Percutaneous Transarterial Embolization via Costocervical Trunk Approach for Patients with Persistent Type II Endoleak and Sac Enlargement of Arch Aneurysm after Thoracic Endovascular Aortic Repair (TEVAR) / 日本心臓血管外科学会雑誌

Among the less reported complications after thoracic endovascular aortic repair (TEVAR) is type II endoleak (T2EL). The intercostal and bronchial artery are known as feeder vessels to T2EL after TEVAR. We experienced two cases of successful treatment of percutaneous transarterial feeder vessels embolization via right costocervical trunk approach for patients with persistent T2EL and sac enlargement of an arch aneurysm after TEVAR. The costocervical trunk route is possible for key vessels to construct a collateral pathway to feeder vessels of the endoleak nidus of T2EL after TEVAR procedures for aortic arch aneurysm. A preembolizational Catheter-Directed CT angiogram (CTA) can be helpful to prevent harmful complications (e.g., spinal cord infarction).

Disección aórtica Stanford tipo B no complicada tratada con reparación aórtica endovascular / Stanford Type B Uncomplicated Aortic Dissection Treated with Endovascular Aortic Repair

Resumen La disección aórtica aguda es una urgencia médica asociada a una alta mortalidad, por lo que es fundamental el diagnóstico precoz a partir de una historia clínica detallada, hallazgos a la exploración física y estudios de imagenología, pilares fundamentales para su diagnóstico. El tratamiento depende de su localización, con recomendación de abordaje quirúrgico urgente para las disecciones agudas de tipo A y principalmente el tratamiento farmacológico en la disección aórtica tipo B no complicada. Presentamos el caso de un paciente del sexo masculino, de origen mexicano, que desarrolló disección aórtica tipo B no complicada, a quien se decidió abordar con tratamiento farmacológico y reparación aórtica endovascular, y presentó una adecuada evolución del cuadro clínico, sin complicaciones al egreso ni durante su seguimiento.

Abstract Acute aortic dissection is a medical emergency associated with high mortality, so an early diagnosis based on a detailed clinical history, physical examination findings, and imaging studies is essential for its diagnosis. The treatment depends on its location, with the recommendation of an urgent surgical approach for acute type A dissections and mainly pharmacological treatment in uncomplicated type B aortic dissection. We present the case of a Mexican male patient who developed uncomplicated type B aortic dissection, that was treated with pharmacological treatment and endovascular aortic repair, and presented an adequate clinical evolution without complications at discharge or during follow-up.

Hemodynamic Analysis of Redissection after Endovascular Repair for One Stanford Type B Aortic Dissection Case / 医用生物力学

Objective Based on hemodynamic analysis, to investigate the cause of distal re-entry tear in Stanford type B aortic dissection after thoracic endovascular aortic repair (TEVAR).Methods A patient with type B aortic dissection was reexamined regularly with computed tomography angiography (CTA) at 1st month, 6th month, 12th month and 24th month after TEVAR. Based on the CTA images in each period, three-dimensional (3D) aorta models were reconstructed to perform morphological analysis and hemodynamic simulation.Results Compared with the diameter at 1st month after TEVAR, the diameter of true lumen at 12 months after TEVAR increased by 1.8 times and the global distortion of aorta increased by 16.67%. At postoperative 1st, 6th and 12th month, the maximum blood velocities at the new entry tear in systole were 69.6%, 33.7% and 92.1% higher than the average ones at distal landing zone, and the maximum wall shear stresses (WSSs) were 2.52, 2.32 and 3.52 times of the average WSSs respectively. In addition, the maximum time-averaged WSS (TAWSS) at 1st, 6th and 12th month after TEVAR were 1.88, 2.53 and 3.62 times of the mean TAWSS respectively.ConclusionsThe morphology of the aorta remodeled after TEVAR, and a sudden change in the diameter of true lumen occurred at distal anchoring zone and continued to increase. As a result, the blood flow velocity in this area accelerated, and the intima was continuously exposed to high WSS, leading to the redissection.

A Case of Thoracic Endovascular Aortic Repair for Subacute Aortic Dissection Stanford Type B in a Patient with Marfan Syndrome / 日本心臓血管外科学会雑誌

A 41-years-old man with Marfan syndrome developed acute aortic dissection Stanford Type B. A new entry was located at the distal aortic arch. Medical treatment was given for a month, but the proximal descending aorta expanded to 50 mm. Because he had undergone partial arch replacement at the age of 36, thoracic endovascular aortic repair (TEVAR) using the synthetic graft as proximal landing zone was performed to close the entry. Six months after TEVAR, the false lumen around the stent graft disappeared. Distal stent graft-induced new entry (d-SINE) did not occur after TEVAR. Three years after TEVAR, we performed thoracoabdominal aortic replacement because of expansion of the residual false lumen without any complication. Endovascular therapy could be useful option for extensive aortic lesion even in Marfan syndrome.

Reparación endovascular de la aorta torácica, resultados a largo plazo / Endovascular repair of the thoracic aorta, long-term results

Resumen Introducción: Las diversas patologías de la aorta torácica descendente, representan una implícita amenaza para la vida, y son potencialmente tratables mediante reparación endovascular. Objetivo: Evaluar los resultados de la reparación endovascular de la aorta torácia descendente (TEVAR). Material y Método: Estudio observacional, retrospectivo y descriptivo, donde se analiza TEVAR, en un período de 10 años (2009 al 2019), en el Hospital Dr. Eduardo Pereira de Valparaíso, Chile. Resultados: Se realizó TEVAR en 31 pacientes, sexo masculino 74,2%, femenino 25,8%, edad promedio 67,8 años (rango 53-85), patologías asociadas: hipertensión arterial sistémica (77,4%), tabaquismo (67,7%) y dislipidemia (38,7%), las indicaciones para TEVAR fueron: el aneurisma de la aorta descendente (51,61%), la disección tipo B crónica complicada (29,03%), y la disección tipo B aguda complicada (19,35%), relacionado al procedimiento se evidenció: morbilidad cardiovascular (12,9%) y morbilidad neurológica (6,45%), complicaciones relacionadas a la endoprótesis (29,03%), incidencia de endofugas (19,35%), estancia hospitalaria promedio de 5,2 días (rango 3 a 17), seguimiento promedio de 47,3 meses (9-108), éxito técnico primario (100%), tasa de reintervención: 3,22%, tasa de supervivencia a 1, 3, 5 años del 96,77%, 93,54 y 90,32% respectivamente, no hubo mortalidad menor a 30 días. Discusión: La evidencia demuestra que TEVAR puede realizarse en forma segura y efectiva, cumpliendo estrictos criterios clínicos y condiciones anatómicas, representando la modalidad de elección para la reparación de las lesiones de la aorta descendente. Conclusión: Los resultados demuestran que TEVAR, representa una excelente estrategia terapeutica, menos invasiva, con baja morbilidad y mortalidad asociada.

Introduction: The pathological injuries of the descending thoracic aorta, represent an implicit threat to life, and are potentially treatable by endovascular repair. Aim: To evaluate the results of endovascular repair of the descending thoracic aorta (TEVAR) in the medium and long term. Material and Method: Observational, retrospective and descriptive study, where TEVAR is analyzed, over a period of 10 years (2009 to 2019), at the Dr. Eduardo Pereira Hospital in Valparaíso, Chile. Results: TEVAR was performed in 31 patients, male sex 74.2%, average age 67.8 years (range 53-85), symptomatic 64.5%, associated pathologies: systemic arterial hypertension (77.4%), smoking (67.7%) and dyslipidemia (38.7%), indications for endovascular repair were descending aortic aneurysm (51.61%), complicated Stanford type B chronic aortic dissection (29.03%), and complicated Stanford type B acute aortic dissection (19.35%), neurological morbidity (6.45%), cardiovascular morbidity (12.9%), complications related to the stent (29.03%), where endoleaks predominate (19.35%), average hospital stay of 5.2 days (range 3 to 17), average followup of 47.3 months (9-108), primary technical success (100%), survival rate at 1, 3, 5 years of 96.77%, 93.54 and 90.32% respectively, there was no mortality less than 30 days or reoperation. Discussion: the evidence shows that TEVAR can be performed safely and effectively, meeting strict clinical criteria and anatomical conditions, which represents the modality of choice for the repair of lesions in the descending aorta. Conclusion: The results show that TEVAR represents an excellent therapeutic strategy, less invasive, with low associated morbidity and mortality.

Hybrid Approach to Complex Stanford Type B Dissection: Unusual Extra-anatomical Bypass (Aorto-Celiac-Mesenteric Bypass) + Thoracic Endovascular Aortic Repair (TEVAR) + Cholecystectomy

Abstract Patients with complex Stanford type B aortic dissection are very difficult to treat. Many methods have been proposed so far in the treatment of these patients, and the emergence of hybrid techniques has made the treatment easier. In this article, we shared the extra-anatomical bypass (aorto-celiac-mesenteric bypass) + thoracic endovascular aortic repair + cholecystectomy operation technique applied to a patient with complex type B aortic dissection.

Open Repair versus Endovascular Repair of Blunt Traumatic Thoracic Aortic Injuries : Short- and Mid-Term Outcomes / 日本心臓血管外科学会雑誌

Objective : The mainstream strategy for blunt traumatic thoracic aortic injuries (BTAI) has been shifting from conventional open repair (OR) to thoracic endovascular aortic repair (TEVAR). Accordingly, we reviewed the short- and mid-term outcomes following surgical procedures of BTAI, comparing OR with TEVAR. Methods : We retrospectively collected data of consecutive cases of BTAI in a single institution from March 2001 to August 2019. Results : Eighteen cases were identified. Of these, 7 patients (38.9%, mean age 62.0±15.2 years) were treated with OR and 11 (61.1%, mean age 61.8±21.3 years) were treated with TEVAR. There was significant reduction in the mean operative duration (OR 444±145 vs TEVAR 65±14 min ; p＜0.001), the mean intraoperative blood loss (OR 2,787±1,578 vs TEVAR 210±376 ml ; p＜0.001), the volume of blood transfusions (OR 5,042±2,219 vs TEVAR 929±751 ml ; p＜0.001), and the mean dose of heparin infusion (OR 20.3±4.1 vs TEVAR 7.9±8.5 ml ; p＜0.01). Postoperative 30-day mortality of OR and TEVAR were 28.6 and 0% (p＝0.14), respectively. There was no endoleak, 1 case of paraparesis, and 1 case of bilateral cerebellar infarction in the TEVAR group. There was no significant difference in the length of stay in the intensive care unit, the duration of hospital stay, the rate of home discharge, or the mid-term mortality and re-intervention rate (average follow-up period of 42.0±56.9 months). Conclusions : Compared with OR, TEVAR took less operative time with less bleeding, and required less blood transfusions and heparin. The short- and mid-term outcomes following TEVAR for BTAI was favorable and TEVAR appears to be applicable as a first-line treatment for BTAI.

A Case of Staged Hybrid Repair for Subacute Type B Aortic Dissection in a Patient with Shaggy Aorta / 日本心臓血管外科学会雑誌

In aortic surgery involving shaggy aorta, surgical strategy to avoid embolism is crucial for each case. We applied the frozen elephant trunk technique to a patient with shaggy aorta. A 79-year-old man was admitted to our hospital for conservative treatment of acute Type B aortic dissection. Dissecting aneurysms of the aortic arch and descending aorta were shown to have rapidly dilated according to CT three weeks later. Preoperative contrast CT showed an ulcerated shaggy aorta from the aortic arch to the mid portion of the descending aorta. To utilize the benefit of the stent compared with the classical elephant trunk technique, we proposed that the frozen elephant trunk technique would be helpful in prevention of embolism. We therefore planned total arch replacement with the frozen elephant trunk technique and performed thoracic endovascular aortic repair. We employed the frozen elephant trunk technique in the first operation and balloon protection of the superior mesenteric artery and the renal artery in the second operation. The patient had an uneventful postoperative course without thromboembolism. The frozen elephant trunk technique may be helpful for patients with shaggy aorta to avoid thromboembolic events.

Stent Graft Implantation into a False Lumen of a Chronic Type B Aortic Dissection after Surgical Abdominal Aortic Fenestration / 日本心臓血管外科学会雑誌

A 57-year-old man, who had suffered chest, back and right leg pain about 10 years before, underwent CT and was found a chronic type B aortic dissection with an enlarged false lumen and a narrowed true lumen that was occluded at the infrarenal abdominal aorta. A conventional surgical repair seemed to be too high risk considering his comorbidities, thus we chose a staged hybrid repair. First, surgical repair of the abdominal aorta with an abdominal aortic fenestration was performed. Then, one month after the first operation, zone 2 thoracic endovascular aortic repair with left carotid-axillary artery bypass was performed. At the second operation, the stent graft was purposely deployed from zone 2 into Th12 level of a false lumen through the fenestration followed by coil embolization of a true lumen just distal to the entry tear. The postoperative course was uneventful and he had no complications at 6 months follow-up. Deploying stent graft into a false lumen could be a feasible option in case deploying into a true lumen is not suitable if the anatomical condition permits.

Arc of Buhler: A lifesaving anatomic variation. A case report / Arco de Buhler: uma variação anatômica que salva vidas - relato de caso

Abstract The presence of malperfusion syndrome in cases of complicated acute type B aortic dissection is a negative predictive factor and urgent intervention is indicated. Anatomic variations, such as the Arc of Buhler, contribute anastomotic channels and can preserve the visceral blood supply. In this case report, we describe the overall management of a 54-year-old man who presented with a type B aortic dissection. Initially, conservative management was chosen, as indicated for an uncomplicated type B dissection, but the dissection deteriorated. Despite the fact that severe occlusion of the celiac artery was detected on Computed Tomography (CT) angiography, the Arc of Buhler anatomical variation was present, contributing adequate visceral blood supply. After considering this finding, the patient was treated effectively with thoracic endovascular aortic repair (TEVAR).

Resumo A presença da síndrome de má perfusão em casos de dissecção aórtica aguda do tipo B complicada é um fator preditor negativo, e uma intervenção urgente é indicada. As variações anatômicas, tais como o arco de Buhler, contribuem como canais anastomóticos e podem preservar o suprimento sanguíneo visceral. Neste relato de caso, descrevemos o manejo geral de um paciente do sexo masculino, de 54 anos, que apresentou uma dissecção aórtica do tipo B. Inicialmente, o manejo conservador foi escolhido, conforme indicado para dissecção do tipo B não complicada, mas a dissecção sofreu deterioração. Apesar de uma oclusão grave da artéria celíaca ter sido detectada na angiotomografia computadorizada, a variação anatômica do arco de Buhler estava presente, contribuindo para o suprimento sanguíneo visceral adequado. Após levar em consideração esse achado, o paciente foi tratado de forma efetiva com reparação endovascular da aorta torácica.

Debranching and Endovascular Repair of a Saccular Aneurysm of the Aortic Arch with Preoperatively Devised, Fenestrated and Branched Stent Grafts (Surgeon-Modified Fenestrated and Retrograde Branched Technique) / 日本心臓血管外科学会雑誌

An 85-year-old man being treated for idiopathic interstitial pneumonia underwent chest CT 6 months prior to the current admission and was diagnosed as having an expanding saccular aneurysm of the aortic arch. Due to the patient's advanced age and the anatomical position of the aneurysm, it was difficult to perform total aortic arch replacement or hybrid arch repair with a commercially available device. After ethical approval had been obtained from the institutional review board, a commercially available stent graft (Relay Plus®) was fenestrated with a 12-mm hole. Under general anesthesia, bypass grafting was performed between the bilateral axillary arteries and the right common carotid artery with a T-shaped ring-supported e-PTFE prosthesis. The fenestrated stent graft was advanced through the left femoral artery and deployed with the device fenestration located at the bifurcation of the brachiocephalic artery. Then, a branched stent graft was deployed through the right common carotid artery in a retrograde manner between the brachiocephalic artery and the ascending aorta through the fenestration to complete the procedure. The patient had an uneventful postoperative course, with no detectable endoleak on postoperative digital subtraction angiography. The current technique, involving the use of an easy-to-make device，is effective for endovascular aneurysm repair, especially when a proximal neck needs to be created in the ascending aorta.

Endovascular repair combined with fenestrated stent grafts in treating aortic arch lesions / 中华胸心血管外科杂志

Objective@#To evaluate endovascular repair combined with fenestrated stent grafts for the treatment of aortic dissection or aneurysm involving aortic arch.@*Methods@#From Jun 2017 to Dec 2018, 30 patients of complicated aortic arch lesions were treated with endovascular repair combined with fenestrated endografts. 26 male and 4 female, aged(53±16) years. All patients had hypertension. 12 cases were treated via needle based in situ fenestration, another 16 cases using physician modified stent grafts, while 2 cases combining these two methods to achieve optimal fenestration. Patients were followed by receiving CTA for mortality, patency of bridging stents, endoleaks and complications.@*Results@#Operations were performed successfully in all cases. The median follow-up is 8.5 months. There was no aorta-related mortality. 1 patient developed cerebral infarction and 1 had hydropericardium. Type Ⅲ endoleaks were observed in 5 patients, no reintervention. All target vessels were patent during the follow up.@*Conclusion@#Fenestrated stent grafts shows satisfactory short-term outcomes in treating aortic arch lesions.

A Case Report after Two Years of Total Debranching and Endovascular Repair for Kommerell Diverticulum / 日本心臓血管外科学会雑誌

A 78-year-old woman with abnormal shadows on computed tomography (CT) was given a diagnosis of right-sided aortic arch and Kommerell diverticulum (KD), accompanied by aberrant left subclavian artery. Although no symptoms were observed, the maximum diameter of the aneurysm was 63 mm, and surgical intervention was chosen because of the possibility of rupture. At first, a 4-branched blood vessel prosthesis with a side branch was anastomosed to the ascending aorta. Next, after reconstructing the cervical branches, a Conformable GORE® TAG® (W.L. Gore and Associates, 34 mm×200 mm) was inserted from the side branch and expanded in the range of Zones 0 to Th 7. Finally, ALSA coil embolization was performed. She was discharged on postoperative day 36, and at her 2-year follow-up, she was doing well, with shrinkage of Kommerell diverticulum.

A Case of Hydrophilic Polymer Embolism after TEVAR / 日本心臓血管外科学会雑誌

Hydrophilic polymer embolism (HPE) associated with endovascular therapy has steadily gained attention. We report a case of a 70-year-old man who had undergone one-debranched TEVAR. He had a history of distal arch replacement for dissecting aortic aneurysm 14 years earlier. Pseudoaneurysm at the proximal site of graft anastomosis was found on computed tomography (CT) angiogram during the follow-up. 1 debranching TEVAR was performed using the pull-through technique. Fourth days after the procedure, a skin rash appeared in the right lower extremity around the access site. Skin biopsy with pathological examination revealed HPE. We decided to observe a patient because there was no symptom of limb ischemia. Skin lesions improved and he was discharged on the 27th postoperative day. Hydrophilic polymers are widely used in the endovascular devices and there is an urgent need to better understand the complication of HPE.

Metronidazole-Induced Encephalopathy in Treatment for a Thoracic Aortic Aneurysm Infected by Bacteroides fragilis / 日本心臓血管外科学会雑誌

A 77-year-old man presented with fever and back pain. Computed tomography revealed a distal arch aneurysm. Bacteroides fragilis was found in a blood culture, and we diagnosed a thoracic infected aneurysm. Because of the rapid enlargement of the aneurysm and his frailty, a TEVAR procedure was urgently performed. He left the hospital after antibiotic treatment with meropenem. However, he was re-hospitalized due to recurrence of the infection. The infection was well-controlled by treatment with intravenous meropenem, and the subsequent oral administration of metronidazole (MNZ). He was re-hospitalized again 7 weeks after discharge due to unsteady gait and articulatory disorder. MNZ-induced encephalopathy (MIE) was diagnosed because FLAIR brain magnetic resonance imaging revealed an area of high signal intensity in the bilateral basal dentate nuclei. These symptoms improved after MNZ was changed to AMPC/CVA. Fifteen months later, the patient was doing well and had no recurrence of the infection. We performed TEVAR for a patient with a thoracic aneurysm infected by B. fragilis. The recurrence of the infection was controlled by adequate antibiotic therapy, which included the administration of MNZ. However, patients who are treated with MNZ should be carefully observed to detect the development of neurological signs, as MNZ may induce encephalopathy. The early detection and withdrawal of metronidazole is important for the improvement of MIE.

Hybrid Technique for Extensive Aortic Arch Aneurysm after Thoracoabdominal Aortic Aneurysm Repair / 日本心臓血管外科学会雑誌

We report a case of operations using a hybrid technique for repeated extensive aortic aneurysm. A 71-year-old man had extensives aneurysms of the aortic arch and descending aorta. In the first operation, he had undergone thoracoabdominal aortic replacement with island repair for thoracoabdominal aortic aneurysm (Crawford type 3) at age 64. Six years later, computed tomography showed an aortic aneurysm around the region of the island repair and penetrating atherosclerotic ulcer (PAU). Therefore, he underwent abdominal debranching and thoracic endovascular aortic repair (TEVAR) at 70 years old. At the same time, he had an extensive aortic arch aneurysm. Considering the complicated surgical history and the affected region, we judged that conventional graft replacement was difficult. So, in the third operation, we performed TEVAR for the descending aorta at 71 years old. One month later, total arch replacement (TAR) with a frozen elephant trunk (FET) was performed (4th operation). The patient was discharged home 22 days after the 4th operation. This strategy of operations using hybrid techniques for extensive aortic aneurysm may be useful in high risk cases of surgical procedures and postoperative complications.

A Case of Total Arch Replacement for Non-anastomotic Pseudoaneurysm by Proximal Stent Graft Induced-Vascular Graft Perforation in Loeys-Dietz Syndrome after Total Aortic Replacement / 日本心臓血管外科学会雑誌

A 26-year-old lady with Loeys Dietz syndrome had undergone 5 consecutive operations from 2007 to 2014. Finally, her total aorta was replaced by vascular grafts and stent grafts. The patient was admitted to our hospital with headache and dizziness in 2016. Computed tomography showed a giant pseudoaneurysm at the aortic arch with extravasation from the vascular graft. The proximal flares of thoracic stent grafts caused perforation of thoracic vascular grafts. Cerebral perfusion was not sufficient, because this aneurysm compressed the innominate, left carotid and left subclavian arteries. Decreasing of cerebral perfusion caused headache and dizziness. We performed total arch replacement. We started extracorporeal circulation before median sternotomy but the aneurysm ruptured during median sternotomy. We controlled the bleeding by manual compression and immediately started selective cerebral perfusion and induced cardiac arrest. After opening the distal portion, we cut down the proximal flares of thoracic stent graft and inserted an elephant trunk into the stent graft. We sutured between the new vascular graft and the stent graft and covered the suture line with another short vascular graft. As a result we could protect the vascular graft from the stent graft. Computed tomography demonstrated that the pseudoaneurysm and extravasation disappeared. Cerebral perfusion increased and the patient's symptoms improved. Postoperatively the patient was discharged from our hospital without any major complications at POD 11.