Fig. 1. Thoracic aortography demonstrates a normal aortic arch and a pseudoaneurysm of the left subclavian artery (arrow).		Fig. 2. The subclavian artery origin was measured using both a marker catheter and a externally placed ruler.

Case Reference No. CC-797-04 An unidentified man approximately 40 years of age was involved in a high-speed motor vehicle accident. His injuries included a C2 cervical fracture. Emergency thoracic aortography demonstrated a traumatic pseudoaneurysm of the proximal left subclavian artery. The size of the vessel was measured with both a calibrated catheter and a radiopaque ruler (Figs. 1, 2). The vessel measured 15­16 mm in diameter at its base. The surgeon declined to perform a thoracotomy and agreed to stent-graft placement. Because of the vessel's large size, emergent stent-graft repair was not performed that night. Over the next several days, the patient's blood pressure was elevated and difficult to control, possibly due to essential hypertension. For this reason, the critical care service kept the patient intubated and deeply sedated until stent-graft repair could be accomplished. After further review by the thoracic surgeon it was decided that the patient should not undergo vascular repair and should be treated with blood pressure medications alone. (Type B dissection protocol).

Questions 1) Do you agree with the surgeon that this lesion should not be repaired, either surgically or percutaneously? 2) If asked, how would you fashion a stent-graft to treat this relatively large but presumably fragile proximal left subclavian artery?