Tilea et al. Journal of Medical Case Reports 2012, 6:255 http://www.jmedicalcasereports.com/content/6/1/255 Page 3 of 4 Figure 2 Contrast-enhanced computed tomography (CT) scan: transversal section (A) frontal plane bi-dimensional reconstruction (B). Image shows a 91×80×71mm aneurysm of the descending aorta. had not suggested this, but at the end of the interven- tional procedure the final angiogram revealed a partially covered ostium of the left subclavian artery by the stent- graft. The surgical possibilities for debranching in this situation were carotid-subclavian bypass or transposition of the left subclavian artery to the left common carotid artery. We chose the second procedure because of the presence of a paraprosthetic leakage originating from the left subclavian artery. The closure of the subclavian artery with sutures resolved both problems: the leakage and the left upper arm and vertebral artery vascularization. Both procedures were successful. Post-procedural evolution was uneventful, except for a fever of a few days duration of up to 38°C, which was related to post-implantation syndrome, with no evidence of infection and mild residual dysphonia. Three months after the procedure, our patient was clinically well without any clinical signs of left lower limb ischemia or new onset neurological abnormalities. Contrast-enhanced CT revealed complete thrombosis of the excluded aneurysm (Figure 4A,B). Discussion We present a case that illustrates the clinical outcomes of surgical intervention for aortic coarctation: residual systemic hypertension, aortic valve disease requiring surgi- cal intervention, and dilatation of the ascending aorta, as well as aneurysm formation at the site of the surgical anas- tomosis, all occurring after Dacron patch plasty. However, such a very late presentation and slow evolution of the local aneurysm are rather unusual. The management of such cases is always difficult, requiring a multidisciplinary approach. Such a large aneurysm is prone to rupture when conservatively treated, but a third surgical intervention would have been of particularly high risk. In this case, a multidisciplinary team decided on a hybrid approach, which confirmed once again the safety and feasibility of this procedure in high-risk patients. Thus, non-surgical re- construction of late, post-aortic coarctation surgery thor- acic aneurysms appears a safe and feasible technique. Interventional stent-graft placement allows avoiding repeated surgical interventions. There are no clear guidelines, however, regarding the best treatment of aortic aneurysm occurring after surgi- cal correction of aortic coarctation. Recent advances in surgical management offer better results from surgical repair in the hand of experts. However, such procedures cannot avoid relatively long circulatory arrest, frequent pulmonary complications, a need for blood products in Figure 3 Angiography with stent-graft: positioning (A), and implantation (B). Immediate post-intervention angiography shows minimal leakage to the dilated left subclavian artery (C).