A blunt thoracic trauma is a rare but potentially life-threatening condition, with prognosis improved by endovascular techniques. Involvement of the aortic arch adds complexity to the intervention, requiring special attention to cerebral perfusion. This case presents a young patient with an aortic injury treated with a temporary bypass and a physician-modified thoracic endograft in the aortic arch, which presented multiple complications in the short and medium term.

A 17-year-old girl, hit by a car, was brought to our center. Upon admission, she was hemodynamically stable but had various traumas, including a pseudoaneurysm of the aortic isthmus. The injury was classified as grade III according to the Azizzadeh classification. A hybrid intervention was chosen to minimize operative time and avoid extracorporeal circulation. After a temporary right subclavian-left carotid bypass to ensure cerebral perfusion, an endograft was placed in the aortic arch, followed by in-situ fenestration for the left carotid artery and left carotid-subclavian bypass. Control angiography showed complete exclusion of the aortic lesion with patency of the brachiocephalic trunk, the carotid-subclavian bypass and the left carotid stent. Cerebral oxygen monitoring showed no abnormalities. Upon removal of the endovascular device, severe resistance was noted, particularly in the right iliac region. A right-sided lumbotomy revealed a contained rupture of external iliac artery, necessitating a reconstruction with an 8 mm silver Dacron graft for a common iliac-common femoral bypass.

There were postoperative complications, including bypass occlusion and hand ischemia, successfully treated. A month later, the patient developed sepsis caused by an infected pseudoaneurysm of the bypass, requiring a new surgery with a bypass using autologous material. A long-term antibiotic therapy was introduced. A six-month follow-up showed a satisfactory outcome.

This case demonstrates that hybrid repair is effective in emergency situations with short proximal landing zones, even in young patients. Perioperative stroke is the most feared complication but not the only one. Small vessel size can pose a challenge, especially in female patients. Lastly, the risk of medium/long-term infection should be promptly recognized and treated.