J Korean Med Sci 2010; 25: 142-4 ISSN 1011-8934 DOI: 10.3346/jkms.2010.25.1.142 Hybrid Procedure for a Traumatic Aortic Rupture Consisting of Endovascular Repair and Minimally Invasive Arch Vessel Transposition without Sternotomy Emergency surgical repair for acute traumatic aortic ruptures has been associated with a high peri-procedural mortality rate. Endovascular stent-grafting, as a less invasive procedure, has shown encouraging results. This report describes a patient with a short landing zone, who was treated by transposing the supra-aortic branch without sternotomy, followed by covered stent-grafting with an extended proximal bare portion to enhance fixation. Key Words : Aorta; Wounds and Injuries; Stent-graft ⓒ 2010 The Korean Academy of Medical Sciences. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Yang Gi Ryu1, Suk Jung Choo2, Ju Yong Lim2, Hyun Ki Yoon3, and Cheol Hyun Chung2 Department of Thoracic and Cardiovascular Surgery1, Guro Hospital, Korea University Medical Center, Seoul; Departments of Thoracic and Cardiovascular Surgery2, Interventional Radiology3, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, Korea Received : 9 May 2008 Accepted : 28 July 2008 Address for correspondence Cheol Hyun Chung, M.D. Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Korea Tel : +82.2-3010-3580, Fax : +82.2-3010-6989 E-mail : hyun227@amc.seoul.kr INTRODUCTION Blunt traumatic aortic rupture (TAR) has traditionally been treated with early open surgical repair. Recently, endovascu- lar stent-grafting of TAR has been described as a less invasive and possibly more favorable option. CASE REPORT A 73-yr-old woman presented with multiple trauma and chest pain after a traffic accident. Traumatic aortic injury was suggested by a chest radiography, which showed mediastinal widening and left pleural effusion. A spiral computed tomog- raphy (CT) scan revealed an extraluminal hematoma in the distal aortic arch with a contained aortic rupture (Fig. 1). Fur- ther examination showed no other aortic lesions. However, the patient had concomitant comminuted fractures in the right tibia, left femur, and the radius bilaterally, which required surgery. Surgery for the TAR was therefore delayed for about 1 month to allow orthopedic postoperative recovery. To allow a minimally invasive surgery, a hybrid aortic stent-grafting procedure was performed, consisting of a left subclavian artery (LSCA) debranching procedure combined with proximal des- 142 cending thoracic aortic stenting. Median sternotomy for the debranching procedure was avoided by transposing the LSCA to the left common carotid artery (LCCA) through a 5 cm left supraclavicular incision. The LSCA and LCCA were dis- sected and freed from their surrounding attachments after moderate systemic heparinization with an intravenous (IV) of 5,000 IU. The proximal LSCA was clamped and transect- ed, and the proximal stump was closed with a continuous running suture of 4-0 polypropylene. The LCCA was partially clamped and opened longitudinally, and the transected dis- tal portion of the LSCA was attached in an end-to-side man- ner. The wound was closed in layers. The patient later recov- ered full neurologic function without deficits. On postoper- ative day 5, the interventional radiologist inserted a thoracic aortic stent percutaneously using the Seldinger technique. The common femoral artery was punctured under local anes- thesia. A 5F-calibrated angiographic catheter was advanced into the aortic arch via the contralateral common femoral artery to determine the morphology and extent of the aortic rup- ture (Fig. 2A). The delivery system was advanced under flu- oroscopy after IV injection of 5,000 IU heparin until the tip reached the origin of the LCCA. Finally a SEAL endopros- thesis (S & G Biotech, Korea) was inserted into the aortic arch to complete the procedure. A series of aortograms were per-