Purpose: To report a challenging carotid intervention after total arch rerouting and hybrid zone 0 elephant trunk repair.
Case report: A 54-year-old man developed symptomatic left carotid artery restenosis 2 weeks after total arch rerouting and hybrid zone 0 elephant trunk repair for acute retrograde type A aortic dissection with left carotid malperfusion. Because the origins of the 3 supra-aortic branches were already transected and rerouted to the proximal end of the reconstructed ascending aortic graft, the peripheral access routes for carotid intervention were deemed difficult, with little chance of success due to acute angles between these rerouted supra-aortic branches and the ascending aortic graft. Emergent carotid artery stenting was therefore performed via sternal reentry with successful restoration of cerebral perfusion.
Conclusion: Total arch rerouting, facilitating hybrid endovascular repair for extensive thoracic aortic disease, creates an extremely deformed arch anatomy that renders subsequent carotid intervention a challenging task.