Conventional open repair for Thoracoabdominal aortic aneurysm (TAA) is associated with high morbidity and mortality. Spinal cord ischemia (SCI), renal failure, bowel ischemia and mortality are established complications following this procedure. With the advent of endovascular stent technology, various novel approaches have been described to reduce these complications, namely fenestrated stent graft and hybrid procedure. We present a case of hybrid procedure in a pseudoaneurysm of descending

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... acic aorta done in Kuala Lumpur Hospital. CASE PRESENTATION Mr MNO is a 64 year old man who presented with epigastric pain for two weeks prior to admission. The pain was dull aching and intermittent in nature and radiating to the back. It was sudden in onset and claimed to be related to food. Examination revealed a soft abdomen with tenderness at the epigastric area. No other abnormalities were detected. He was initially treated as acute pancreatitis but Computed Tomography scan (CT scan) showed a saccular lower descending thoracic aneurysm with the distal end just above the coeliac axis measuring 4.5x 4.3cm. A small infrarenal abdominal aortic aneurysm measuring 3.5cm with calcification and narrow iliac vessels were also noted. He was treated with intravenous Ceftazidime 2g twice daily for his symptomatic pseudoaneurysm of the lower thoracic aorta. After one week of intravenous Ceftazidime, he underwent a Stage I hybrid procedure repair, involving a bypass procedure to the coeliac and SMA arteries. However intraoperatively, both of his iliac arteries were noted to be very small and heavily calcified with a small aortic aneurysm. Thus, an aortobifemoral bypass with a 18 x 9mm graft was done as preparation of the access vessel for endovascular repair. Then a bypass from the left limb graft to the coeliac axis with a 9mm graft was done, followed by another bypass from the body of the bypass graft to the Superior Mesenteric Artery. Both the Coeliac axis and SMA were ligated at their aortic root to prevent retrograde flow. Stage II repair of the hybrid procedure was done 10 days later, once the patient's condition stabilized clinically and biochemically. A right groin crease incision was made and the right graft limb was exposed and secured. The left graft was punctured percutaneously with a 18G needle, followed by insertion of a 5Fr sheath on a 0.035" guide wire. A calibrated pigtail catheter was inserted and an aortogram was performed to localize the area of deployment. A Valiant Thoracic Stent Graft with a Xcelerant delivery system with size of 28x24x150 and 24x24x150 was introduced through the exposed right limb graft and successfully deployed just above the renal arteries with no evidence of a endoleak. The patient was sent to the Intensive Care Unit (ICU) and was extubated an hour postoperatively. His general condition was stable and feeding was started the next day. However, 32 hours postoperatively, he developed profound paraplegia with a lax anal tone, hence spinal cord ischemia was suspected. A spinal drainage catheter was inserted at the level of L3/L4 and the cerebrospinal fluid (CSF) pressure was noted to be 18mmHg. CSF drainage was done intermittently and the pressure was brought down to the level below 15mmHg. The paraplegia remained the same and he was discharge back to the general ward on the third day of ICU care. His general condition remained stable and rehabilitation therapy for his paraplegia was commenced. He was discharged after ten days postoperatively. DISCUSSION Thoracic aortic aneurysm management poses a great challenge to the vascular surgeon. Spinal cord ischemia, stroke and high mortality rates are recognized complications of descending thoracic (DTA) and thoracoabdominal aortic (TAA) operations 1. Early mortality after thoracoabdominal surgery and spinal cord ischemia post procedure is as high as