Management of recurrent ascending aortic aneurysm with bovine arch and aberrant right subclavian artery utilizing bilateral carotid to subclavian transposition followed by thoracic endovascular aneurysm repair.

We present a case of a 68-year-old man with variant anatomy and a history of prior Bentall procedure with open ascending aortic aneurysm repair, who presented with a recurrent pseudoaneurysm at the previous surgical distal anastomosis. His management was complicated by an aberrant right subclavian artery and bovine arch anomaly. The patient was managed using a staged approach consisting of a bilateral carotid to subclavian transposition followed by thoracic endovascular aneurysm repair. This technique allowed for the successful placement of an endograft to exclude both the aneurysm sac and the bovine arch. This case highlights the effectiveness of a staged approach in managing complex aortic pathologies.