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Thirty years ago Bentall described a technique for composite aortic valve and root replacement with reimplantation of the coronary arteries.1 In Bentall’s operation, as originally described, the aneurysmal aorta is wrapped snugly around the graft, greatly assisting haemostasis. Haemorrhage through a porous graft, and through stitch holes, is contained until reversal of heparin. Although life endangering bleeding may be controlled with this technique, occasionally an anastomotic leak persists to become a fistula, connecting the conduit with the space between the conduit and the remains of the native aorta, as seen in this case. Such a perigraft false aneurysm may cause pressure on the pulmonary artery, or the superior vena cava, or distort one of the coronary arteries. It is for this reason that complete excision of the affected aorta and end to end anastomosis (rather than Bentall’s inclusion technique), is now advocated by surgeons who operate regularly on degenerative disease of the ascending aorta. An enlarging perigraft aneurysm should be carefully monitored, most simply by transthoracic echocardiography. Repair of the leak, usually with the aid of femorofemoral bypass, should be considered. (a, Native aortic root; A, false lumen; arrow, position of fistula.)
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