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Objective. To present a challenging case of a patient with contained ruptured aneurysm of her aortic arch as well as a saccular aneurysm of the descending thoracic aorta with a history of previously repaired abdominal aortic aneurysm.

Methods. Technical considerations for the placement of the endograft required us to perform extra anatomic reconstruction in the form of a right carotid to left carotid artery bypass, and a left carotid to left subclavian artery bypass. This provided the 2 cm proximal landing zone required for endovascular repair of the arch aneurysm. A 34 x 34 x 115 mm Talent (Medtronic EndoVascular, Minneapolis, Minnesota) thoracic graft was used to exclude the arch aneurysm. In addition, a separate 32 x 32 x 48 mm Talent cuff graft was used to exclude the saccular aneurysm located in the descending thoracic aorta. The intervening native aorta was left untouched.

Results. The patient recovered well with no evidence of paralysis.

Conclusion. When planning the repair of an aortic aneurysm, consideration must be given not only to the ability to cover the aneurysm, but to the consequences of doing so. We feel that precautions should be taken to cover as little of the native aorta as possible to decrease the associated risk of paraplegia in patients whose abdominal aorta has been replaced.