Objective

A 76 year old man underwent emergency dissection surgery in 2011. He declined surgery when he presented 6 months post-surgery mildly febrile with frank haemoptysis and a confirmed pseudoaneurysm arising from the graft/sinotubular junction anastomosis. He represented 4 years later with a massive pseudoaneurysm extending through the thoracic inlet and eroding the posterior sternal table. The pseudoaneurysm was entered when the sternum was re-opened under deep hypothermic circulatory arrest. Circulation was recommenced after replacing the distal aorta with a new side-armed vascular graft. The preexisting ascending graft was replaced by a second vascular graft and anastomosed to the distal graft. The patient was rewarmed and weaned from circulatory support. He had a protracted recovery with a left hemiparesis but is making steady progress. The video demonstrates the operative steps on how a successful outcome can be achieved for a difficult emergency procedure.