Silent right coronary artery pseudoaneurysm detected 13 years after modified Bentall procedure: a case report

Introduction and importance: The Bentall procedure provides excellent long-term outcomes for patients with aortic root pathology, yet delayed coronary button complications may occur many years after surgery. Very late pseudoaneurysms of the right coronary artery (RCA) button are exceedingly rare and highlight the importance of lifelong surveillance imaging. Case Presentation: A 46-year-old man with hypertension, dyslipidemia, and prediabetes, who underwent a modified Bentall operation in 2010 for an aortic root aneurysm and severe aortic regurgitation, was found incidentally to have a right coronary button pseudoaneurysm 13 years postoperatively during routine computed tomographic angiography (CTA). An infectious workup, including C-reactive protein and serial blood cultures, ruled out infection. Elective reoperation was performed, consisting of Dacron patch repair of the aortic root graft defect and a saphenous vein bypass graft to the distal RCA. The postoperative course was uneventful, and follow-up CTA at 6 months demonstrated complete resolution of the pseudoaneurysm. Clinical discussion: Late coronary pseudoaneurysm formation may result from suture line degeneration, chronic mechanical stress, and cardiovascular risk factors rather than infection. Because these lesions can remain clinically silent for years, periodic cross-sectional imaging plays a crucial role in early detection, especially when echocardiography is limited. Surgical repair with secure closure of the anastomotic defect and bypass grafting offers durable results in selected patients. Conclusion: Very late RCA button pseudoaneurysm can occur more than a decade after a Bentall procedure, despite previously normal follow-up imaging. Lifelong, risk-based surveillance and timely elective intervention remain essential for preventing catastrophic rupture and ensuring long-term safety.