blunt traumatic aortic rupture ( tar ) has traditionally been treated with early open surgical repair . recently ,
endovascular stent - grafting of tar has been described as a less invasive and possibly more favorable option .
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 tomography ( ct ) scan revealed an extraluminal hematoma in the distal aortic arch with a contained aortic rupture ( fig .
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 descending 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 dissected and freed from their surrounding attachments after moderate systemic heparinization with an intravenous ( iv ) of 5,000 iu .
the proximal lsca was clamped and transected , 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 distal portion of the lsca was attached in an end - to - side manner .
on postoperative day 5 , the interventional radiologist inserted a thoracic aortic stent percutaneously using the seldinger technique .
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 rupture ( fig .
the delivery system was advanced under fluoroscopy after iv injection of 5,000 iu heparin until the tip reached the origin of the lcca .
finally a seal endoprosthesis ( s & g biotech , korea ) was inserted into the aortic arch to complete the procedure .
a series of aortograms were performed during deployment to ensure accurate proximal and distal positioning .
the proximal bare stent was placed precisely in the middle of the ascending aorta , allowing free blood flow to both arch vessels .
intraoperative angiography was used for post - procedural assessment of stent - graft positioning and endoleak ( fig .
2c ) showed successful exclusion of the rupture site , with no any signs of endoleak or graft - related complications . at the first visit to the out - patient department
, the patient was doing well and showed good healing of the supraclavicular incisional wound ( fig .
emergency open thoracotomy for traumatic aortic ruptures is associated with a peri - procedural mortality rate ranging between 17% and 21% , and a paraplegia rate as high as 7% ( 1 , 2 ) , due mainly to the large proportion of patients who present with multiple concomitant co - morbid conditions .
although delaying surgical repair of tar may overcome the high mortality and morbidity risks associated with emergency surgery , delaying open surgery has been found to have an in - hospital mortality risk of 2 - 5% ( 3 , 4 ) .
recent results have suggested that endovascular stent - grafting may be a viable , ' minimally invasive ' alternative , which can achieve the same results as emergency open thoracotomy but with lower mortality and morbidity risks ( 5 - 7 ) .
endovascular stent - grafting , however , has several drawbacks that may limit its broader application .
for example , most tars occur at the aortic isthmus level , so the proximal landing zone in these patients is usually short . furthermore , obligate coverage of the lsca ostium
is often required to achieve complete sealing of the rupture site , so it may cause ischemia or thrombosis ( 8 , 9 ) .
proximal fixation was enhanced in our patient by deploying a graft with an extended bare proximal portion .
this approach could ensure adequate anchorage without aortic arch branch occlusion , even in patients with short landing zones .
furthermore , by transposing the lsca onto the lcca through the small supraclavicular incision , a full sternotomy could be avoided while preserving blood flow to the lsca .
occlusion of the lsca during unprotected stent insertion is frequently regarded as inconsequential . in summary , this report presents our first experience with hybrid tar , combining supra - aortic branch transposition with endovascular stent - grafting .
currently available techniques for stent - grafting of the descending aorta , combined with minimally invasive debranching procedures , may lead to the further development of safe and effective strategies that will avoid the high risks associated with conventional open surgery .
 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 . 
INTRODUCTION
CASE REPORT
DISCUSSION