PMC5487262_01
Acute type B aortic dissection with retrograde affliction of the aortic arch.
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Additionally, an emergency computed tomography (CT) scan performed upon the patient's arrival revealed an acute Stanford type B aortic dissection with retrograde affliction/hematoma of the aortic arch ( Fig. 1 ). 
Hybrid aortic arch repair with initial debranching procedure. End-to-side Y-graft from ascending aorta, end-to-end anastomoses to brachiocephalic artery and left common carotid artery; extraanatomic left carotidsubclavian bypass; and thoracic endovascular aortic repair (TEVAR, proximal landing zone [PLZ] 0).
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Computed tomography (CT) scan confirming active bleeding (
A
). Intraoperative findings of ascending aorta tear and active bleeding (
B
).
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Emergent CT scan confirmed active bleeding in the mediocaudal region of the ascending aorta/bypass anastomoses and relevant pericardial effusion ( Fig. 3A ). We discovered active bleeding directly spurting above the ascending aortic anastomosis with the Y prosthesis, which appeared to be torn by the implanted stent ( Fig. 3B ).
Redo surgery with replacement of the supracommissural ascending aorta with a Dacron prosthesis, which was anastomosed to the stent graft excluding the rigid metal struts. Antegrade cerebral perfusion via the Y-graft. Reanastomosis of the Y-graft to the aortic prosthesis in end-to-side technique (
A
). Control computed tomography (CT) scan after 5 days (
B
) and 6 months (
C
).
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Bypasses to the carotid arteries were reanastomosed in an end-to-side technique ( Fig. 4A ). A control CT scan after 6 months confirmed patency of all anastomoses ( Fig. 4C ).