Hybrid Management of Subclavian-Axillary Artery Aneurysms in Loeys-Dietz Syndrome After Prior Aortic Arch Repair: Technical Note

INTRODUCTION: Syndromic hereditary thoracic aortic disease (sHTAD), including Loeys-Dietz syndrome (LDS), often lead to aneurysmal disease with diffuse arterial involvement. Although open repair remains the gold standard in sHTAD, it carries significant morbidity. Herein, a hybrid approach for subclavian-axillary arterial aneurysm repair in patients with LDS is described. TECHNIQUE: Two patients with prior aortic repair extending from the aortic root to the abdominal aorta were managed for extensive aneurysms involving the subclavian and proximal axillary artery. Via ipsilateral upper limb access, the prior proximal repair was extended with multiple self-expanding covered stents to the axillary artery, ensuring adequate overlap. The distal stent was exposed through a transverse arteriotomy, and an end-to-end anastomosis was created by incorporating the covered stent and arterial walls. In both cases, no salvage of the vertebral arteries was attempted; they were either covered or coiled. Mid-term follow-up showed no anastomotic pseudoaneurysms, kinking, or stenosis. One patient developed a persistent type II endoleak without sac enlargement and remains under surveillance. CONCLUSION: Hybrid repair with endovascular stent implantation, proximal non-native landing zone and open distal anastomosis may offer a safe and effective alternative for complex subclavian-axillary aneurysms in patients with LDS.Clinical ImpactSyndromic hereditary thoracic aortic disease can result in aneurysms with extensive arterial involvement, and open repair remains the gold standard in these patients. A hybrid technique, involving endovascular extension of a previously replaced proximal landing zone to a distal native arterial segment, followed by open exposure and creation of an end-to-end anastomosis, is described. This approach was successfully applied in 2 cases, both with prior open and endovascular management of the proximal landing zone. Mid-term postoperative outcomes demonstrated acceptable efficacy and confirmed the feasibility of the technique. This hybrid approach may significantly reduce postoperative morbidity compared with conventional open repair.