Incidentally detected elevated jugular venous pressure revealing a delayed post-CABG ascending aortic pseudoaneurysm near a saphenous vein graft origin: a case report

Abstract

Ascending aortic pseudoaneurysm is an uncommon but potentially life-threatening delayed postoperative complication of cardiac surgery, arising at previous aortic manipulation sites. It may remain clinically silent until expansion, compressive effects, contained rupture, or catastrophic haemorrhage occurs. A 72-year-old man with hypertension remained well 30 months after off-pump coronary artery bypass grafting until his general practitioner incidentally detected elevated jugular venous pressure during a consultation for influenza-like symptoms. He denied chest pain, dyspnoea, orthopnoea, syncope, or weight loss. Transthoracic echocardiography showed preserved biventricular systolic function, left ventricular dilatation, moderate aortic regurgitation, proximal ascending aortic dilatation, and an extracardiac mass compressing the right atrium. Electrocardiogram (ECG)-gated computed tomography (CT) angiography of the heart and thoracic aorta demonstrated aneurysmal enlargement of the proximal ascending aorta to approximately 5.6 cm, complicated by a giant partially thrombosed pseudoaneurysm measuring approximately 7.5 cm. The lesion communicated with the aorta through a broad neck and showed contrast leakage into the sac, consistent with an actively leaking pseudoaneurysm or contained rupture. It arose within a few millimetres of a proximal saphenous vein graft origin supplying the right coronary territory, compressed the right atrium and superior vena cava, and lay close to the posterior sternum, indicating substantial redo-entry risk. These findings explained the raised venous pressure despite the absence of florid superior vena cava syndrome. Transoesophageal echocardiography confirmed severe aortic regurgitation. The patient underwent high-risk redo median sternotomy with right axillary arterial cannulation before re-entry, cardiopulmonary bypass with cooling to 17 °C and aortic cross-clamping without circulatory arrest, bioprosthetic aortic valve replacement, supra-coronary ascending aortic replacement, and reimplantation of bypass graft inflow. Postoperative haemorrhagic tendency requiring re-exploration settled with supportive management, and he was discharged on postoperative day 14. At 18-month follow-up, he remained asymptomatic, with echocardiography showing a normally functioning aortic bioprosthesis and preserved biventricular systolic function. A delayed post-coronary artery bypass grafting ascending aortic pseudoaneurysm may present with minimal symptoms and be uncovered by elevated jugular venous pressure due to right atrial/superior vena cava compression. ECG-gated CT is essential for confirming pseudoaneurysm/contained rupture, defining graft and retrosternal relationships, and guiding safe definitive repair in high-risk redo surgery.