SINE is a major complication of TEVAR [1]. New intimal tears after stent graft insertion can be caused by aortic wall fragility or irritation caused by the stent graft [2]. SINE is generally believed to develop in patients with acute or chronic aortic dissection [3]. In the acute phase, because the intimal membrane is thinner and stretches more easily, it can expand and recover its original shape very easily after TEVAR [1]. In the chronic phase, however, the intimal membrane is thicker and more fibrotic than in acute aortic dissection. For this reason, the expansile force of the stent graft persistently injures the rigid true lumen [4]. The intima can then ultimately develop new intimal tears, resulting in aortic dissection.

In this case, SINE had developed in the proximal site 6 years after the first TEVAR. In past reports, SINE had occurred in the acute phase or up to 3 years postoperatively; this is the first report of SINE developing after 6 years postoperatively [5, 6]. Ma et al. [7] reported that a > 15% oversize ratio at the first TEVAR for aortic dissection and a stent graft length of < 145 mm were risk factors for SINE. Our patient did not have these risk factors. Our case is considered rare because Ma et al. [7] reported that a CTAG positioned at Z3 resulted in SINE less frequently than when other TEVAR devices were used.

Hemiarch replacement was considered, and we judged that the margin of the aortic anastomosis in the proximal site from the innominate artery could not be ensured when the entry was removed. We decided to perform partial arch replacement to reconstruct the innominate artery. As a result, we avoided total arch replacement. If we had trimmed the distal anastomosis site at Z3, we might have faced the complicated problem whether we cut the CTAG strad.