From complexity to cure: hybrid management of a giant Innominate artery pseudoaneurysm

A 72-year-old man presented with a six-month history of intermittent fever and elevated inflammatory markers (C-reactive protein 13.6 mg/L; erythrocyte sedimentation rate 60 mm/h). He denied any history of trauma, infection, or prior cardiothoracic surgery. Contrast-enhanced computed tomography angiography revealed a 46 × 36 mm pseudoaneurysm at the terminal segment of the innominate artery, containing mural thrombus and communicating with the parent vessel via a 5-mm neck (Figure 1(A–C); Supplementary Video 1). Although infective work-up was declined by the patient, the clinical and imaging features raised strong suspicion for an infectious aetiology. A hybrid repair was therefore performed: first, a right carotid–subclavian bypass using an 8 mm GORE-TEX graft, followed by endovascular exclusion of the pseudoaneurysm with a 12 × 100 mm GORE PLC covered stent. Adjunctive embolisation of the residual sac was achieved using detachable coils and a 14–16-mm Amplatzer vascular plug (Figure 1(D); Supplementary Video 2). The patient recovered uneventfully, completed a two-week course of oral cefuroxime axetil, and remained afebrile at three-month follow-up with complete resolution of symptoms. Infectious pseudoaneurysms of the innominate artery are exceedingly rare, typically arising post-trauma or post-surgery [Citation1,Citation2]. This case presents a rare instance of an innominate artery pseudoaneurysm manifesting with systemic inflammation in the absence of preceding trauma or iatrogenic injury. The adopted hybrid strategy—combining carotid–subclavian bypass, endovascular exclusion, and adjunctive embolisation—represent a less invasive yet effective option for managing such complex supra-aortic lesions, potentially offering durable exclusion while maintaining cerebral perfusion. The uneventful recovery and symptom resolution at three months support hybrid repair as a viable strategy in select cases, though long-term surveillance remains essential given the risk of late graft infection or recurrence.