Video-assisted open repair of proximal thoracic aortic pseudoaneurysm.

Open surgery remains an essential alternative for descending thoracic aortic aneurysms repair when anatomical constraints preclude endovascular intervention. We present the case of a 63-year-old woman with a complex pseudoaneurysm located at the junction of the distal aortic arch and proximal descending aorta (zones 3/4), approximately 7 mm distal to the origin of the left subclavian artery. The absence of a proximal landing zone rendered thoracic endovascular aortic repair unfeasible. A limited left thoracotomy was performed at the fourth intercostal space. Cardiopulmonary bypass was established with femoral venous and double arterial cannulation (aortic arch and distal thoracic descending aorta). A debranching bypass to the left subclavian artery was created using an 8 mm graft. After proximal and distal clamping, the pseudoaneurysm was resected and replaced with a bevelled 32 mm Dacron graft. Long-shafted instruments under video-assistance enabled precise dissection despite limited exposure and dense adhesions. The patient had an uneventful recovery, with no neurological complications and timely discharge. This case illustrates that open aortic repair can be safely and effectively performed through less invasive access in anatomically complex situations. Incorporating modern techniques allows the refinement of open surgery, preserving its relevance in contemporary thoracic aortic management.