Complex endovascular repair of type B aortic dissection and predicting left arm ischemia: a case report

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the gold standard for surgical management of descending thoracic aortic pathology. Depending on the anatomy, TEVAR often requires deployment across the origin of the left subclavian artery (LSA) to obtain a proximal seal, thus potentially compromising perfusion to the left upper extremity (LUE). However, in most patients this is generally well tolerated without revascularization due to collateralization from the left vertebral artery (LVA). CASE PRESENTATION: We present a complex 59-year-old Caucasian patient case of TEVAR with a history of prior arch debranching and intraoperative LSA coverage requiring subsequent LSA embolization and emergency take-back for left carotid–subclavian bypass. CONCLUSION: The purpose of this case report is to highlight an often overlooked anatomic LVA variant and an atypical, delayed presentation of acute LUE limb ischemia.