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A giant aneurysm of the distal arch after stenting and carotid-subclavian bypass by type B dissection. A 64-year old female with type B dissection and expanding distal arch who underwent stent implantation covering the left subclavian artery and carotid-subclavian bypass 8 years ago, presented with dysphagia and distal aortic arch aneurysm. Although the aneurysm (Figs 1 and 2) was excised successfully through a clamshell approach, she suffered a fatal respiratory failure. Figure 1: (A–D) Preoperative computer tomography showing the giant distal aortic arch aneurysm and the stent in the true lumen. The left subclavian artery, which was sacrificed at the initial procedure and the false lumen were open (A and B), resulting in a 7-cm aneurysm (C and D).