Tilea et al. Journal of Medical Case Reports 2012, 6:255 http://www.jmedicalcasereports.com/content/6/1/255 reinterventions require a complex approach, including cir- culatory arrest, frequent use of blood products and a pro- longed hospital stay. Moreover, surgical revision is associated with significant morbidity by paraplegia, injury of the central nervous system, or bleeding and 14% in- hospital mortality rates [7-9]. The use of balloon- expandable endovascular stents has been previously reported as successful in both primary treatment of coarc- tation and recoarctation of the aorta [9,10]. This technique also makes it possible to avoid a major surgical procedure and its inherent risks [1,11,12]. Ince et al. reported no mortality and minimal morbid- ity in a series of six patients treated by percutaneous techniques and endovascular graft implantation for aneurysms occurring after previous repair of an aortic coarctation [1]. These results are significantly superior to those seen with open surgical treatment, which have 14% to 23.5% mortality rates [6,13]. Case presentation Almost two years ago, a 64-year-old Caucasian man was referred to our Cardiology Department for evaluation of back pain and shortness of breath on minimal physical activity. He had a long medical history, including surgi- cal repair of aortic coarctation by Dacron patch plasty at the age of 26, with residual systemic hypertension. He also underwent bi-leaflet prosthetic valve (Sorin Biocar- bon 27) implantation for severe degenerative stenosis of the bicuspid aortic valve at the age of 54. Twelve years previously he had been referred to hospital for ischemic stroke with left hemiparesis. On that occasion he was diagnosed as having a 5cm diameter asymptomatic aneurysmal dilatation of the thoracic aorta at the site of the first surgical procedure. Given the lack of symptoms at that time, the decision was made to follow him with regular reassessments. Twelve years later, given the onset of symptoms, he was hospitalized in our department. At admission, physical examination revealed stable vital signs, blood pressure at Page 2 of 4 160/80mmHg, normal heart rate at 64 beats per minute, stony dullness to percussion of the left posterior thorax, and no evidence of left ventricular dysfunction at rest. An electrocardiogram showed sinus rhythm, first-degree atrioventricular block with a PQ interval of 280 millise- conds, left bundle branch block and rare ventricular pre- mature beats. Conduction abnormalities had been already documented during previous evaluations. Initial evaluation consisted of a plain chest radiograph, which showed a well-contoured opacity with a diameter of approximately 10cm, next to the left border of the aorta (Figure 1A,B). The chest contrast-enhanced com- puted tomography (CT) scan confirmed the presence of a large dilatation of the thoracic aorta (Figure 2A,B). Trans- thoracic echocardiography found good left ventricular systolic function, normofunctional aortic prosthesis, no abnormalities of the native valves, absence of pulmonary hypertension, absence of pericardial effusion, and a dilated (49mm) ascending aorta and aneurysmal descend- ing thoracic aorta. Coronary angiogram and aortography performed in the same session showed no significant lesions of the epicardial vessels and location of the aortic aneurysm immediately below the left subclavian artery. A multidisciplinary team, including a cardiologist, car- diovascular surgeon, angiographist and radiologist, decided on a hybrid resolution of the aneurysm. One year after the last evaluation successful exclusion of the aneurysm was carried out by percutaneous stent- graft implantation (Proximal Free Flow Straight Valiant ThoracicW TF3232C200X, Medtronic Inc., Minneapolis, MN, USA) using a right femoral approach (Figure 3A,B). The stent-graft partially covered the ostium of the left subclavian artery and a paraprosthetic leakage was observed (Figure 3C). The percutaneous intervention was continued with the surgical transposition of the left sub- clavian artery to the left common carotid artery within the same session. The post-procedural debranching had to be done because of the occlusion of the left subclavian artery during the procedure. Pre-procedural evaluation Figure 1 Chest radiography: antero-posterior (A) and left latero-lateral (B).