A Giant Atherosclerotic Ascending Aortic Aneurysm (13.5 cm) With Arch Involvement Successfully Managed by Valve-Sparing Total Arch Replacement: A Case Report

Giant ascending aortic aneurysms (AscAAs), conventionally defined as aneurysms exceeding 10 cm in diameter, are exceedingly rare in contemporary practice due to earlier diagnosis and prophylactic surgical intervention.AscAAs of atherosclerotic origin are particularly uncommon because proximal thoracic aortic aneurysms are typically associated with medial degeneration, connective tissue disorders, or bicuspid aortic valve disease rather than advanced atherosclerosis.Reports of aneurysms exceeding 13 cm remain exceptional in the literature.We report the case of a 70-year-old woman with multiple cardiovascular risk factors, including heavy tobacco exposure and type 2 diabetes mellitus, who presented with progressive dyspnea, constitutional symptoms, and hemodynamic compromise.Computed tomography angiography demonstrated a giant AscAA measuring 13.5 cm with extension into the aortic arch (8.7 cm), associated with periaortic fluid and imaging features suggestive of impending rupture.The aortic root and descending thoracic aorta were spared.Emergency open surgical repair was successfully performed using supracoronary ascending aortic replacement, total arch replacement under deep hypothermic circulatory arrest, and separate supra-aortic branch reconstruction with a branched Dacron graft.Histopathology confirmed an atheromatous aneurysm with thrombotic degeneration, while microbiological studies excluded infection.This case highlights the extreme rarity of massive atherosclerotic AscAAs and demonstrates that successful treatment is achievable through advanced, anatomy-driven open surgical reconstruction.Complete valvesparing total arch replacement with separate branch vessel reconstruction provided durable exclusion of extensive disease while preserving native root structures.This report adds to the limited literature on extreme-diameter ascending aneurysms and underscores the importance of prompt diagnosis and individualized operative planning.