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A 49 year old man presented with progressive dyspnoea eight years after a Bentall procedure for acute dissection of the ascending aorta. Transoesophageal echocardiogram showed a pseudoaneurysm of the aortic prosthesis of approximately 10 cm diameter filled with blood and thrombus around the prosthesis (below left, large arrow). During coronary angiography the catheter spontaneously passed an opening between the aortic prosthesis and the aorta at the distal anastomosis revealing a large pseudoaneurysm. Contrast injection into the ascending aorta revealed a leakage 3 cm above the aortic valve at the approximate location of the left coronary button with a second leakage at the distal anastomosis (panel A, upward pointing arrow). The ostium of the left coronary artery (LCA) was situated approximately 4 cm from the aortic prosthesis (arrow). A channel was formed through the pseudoaneurysm (PsAn) by which the LCA was filled. It is remarkable that the patient had no anginal complaints at admission, although the left coronary ostium was completely severed from the aorta. Angiography (panel B) of the right coronary artery (RCA) showed a narrowing of the proximal part probably caused by elongation of the RCA (white arrow) from the aortic prosthesis to the edge of the pseudoaneurysm (black arrow). Surgery with total revision of the Bentall was proposed. However, the patient died during surgery because of massive bleeding from the pseudoaneurysm caused by incomplete cross clamping of the aorta, the inability to locate the LCA ostium for cardioplegic perfusion, and subsequent severe metabolic acidosis.
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