common carotid artery (CCA). Complete cerebral protection was achieved by direct clamping after systemic heparin was given. Retrograde carotid access was then obtained. All patients were implanted with a balloonexpandable stent over the lesion. In two patients a kissing stent technique was performed, with surgical exposure of axillary artery in one patient and ultrasound-guided puncture in the other, due to extensive lesions of the IA with extension to the right SCA. Direct removal of potential embolic material was performed prior to clamp removal. Clamping time of the CCA was under 15 minutes in all patients. The postoperative period was uneventful, without cerebrovascular ischemic events and resolution of the admission symptoms. Mean follow-up time was 19.8 months. During follow-up, all patients remained asymptomatic and there were no signs of restenosis. Conclusion-The present case series demonstrates the feasibility of a hybrid approach to treat IA lesions with complete cerebral embolic protection. This method allows safer embolic protection compared to a totally endovascular approach with lesser morbidity than open surgery.

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Aberrant origin of the left vertebral artery (LVA) can pose a challenge during thoracic endovascular aortic repair. We encountered such a patient who was involved in a motor vehicle accident in whom computed tomography angiography revealed a grade IIIB blunt aortic injury with an anomalous origin of the LVA distal to the origin of the left subclavian artery. On-table aortography confirmed dominance of the LVA. Hence, an open left carotid-vertebral and then left carotid-subclavian artery bypass was performed, followed by thoracic endovascular aortic repair. The patient recovered well and was discharged home 3 days later.

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