Ascending Aortic Pseudoaneurysm Near the Right Coronary Ostium

Ascending aortic pseudoaneurysm is a rare late complication of aortic surgery. Transcatheter closure is an option for patients at prohibitive surgical risk, but when the neck lies near a coronary ostium, device sizing alone does not predict the final position of the expanded disc. An 82-year-old woman with prior type A dissection repair and subsequent root replacement developed an enlarging ascending aortic pseudoaneurysm with a 15.8 × 13.1 mm neck adjacent to the right coronary ostium. Before intervention, the anticipated footprint of a 12-mm septal occluder was projected geometrically onto 3-dimensional computed tomography reconstruction using the intended working projection; the ostium remained just outside the predicted disc margin. The coronary artery was wired prophylactically, the device seated as predicted, and angiography and echocardiography confirmed sac exclusion with an unobstructed vessel. Projecting the expanded occluder footprint onto computed tomography settled device selection, working projection, and coronary protection preprocedurally rather than by intraprocedural assessment.