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Introduction: Aortic arch anomalies are common; however, the presence of concomitant pathology may present a complex management problem. Report: A 42 year old lady with anomalous right subclavian artery was found to have recurrent coarctation of the aorta and an aneurysm related to the previous repair. Management of the aneurysm was complicated by the proximity of subclavian artery origins. Bilateral subclavian-to-carotid transposition was undertaken to preserve antegrade vertebral artery flow, with subsequent exclusion stent-grafting of the aneurysm and coarctation.Discussion: This case illustrates combined surgical and interventional radiological repair to deal with a complex thoracic aortic clinical problem.