Giant Aortic Root Aneurysm Treated With Bentall Procedure: Technical Pearls and Intraoperative Strategies

Abstract

Giant aortic root aneurysms are rare and potentially life-threatening, especially when the diameter exceeds 10 cm. These cases require urgent surgical intervention and pose significant technical challenges due to the risk of rupture, distorted anatomy, and associated valve dysfunction. We report the case of a 58-year-old man who presented with acute chest pain and refractory hypertension. Transthoracic echocardiography revealed severe aortic regurgitation, a dilated left ventricle with an ejection fraction below 30%, and an aortic root estimated at over 11 cm. CT angiography confirmed a giant aortic root aneurysm without dissection. Given the imminent risk of rupture, the patient underwent emergent open surgical repair. Axillary artery cannulation and early heparinization were performed to minimize intraoperative risk. Heparin was administered after axillary artery cannulation and before sternotomy to enable immediate initiation of cardiopulmonary bypass in case of rupture. A standard Bentall procedure using a 27 mm mechanical valved conduit and 30 mm Valsalva graft was successfully completed. The postoperative course was uneventful, and follow-up at three and nine months showed excellent clinical recovery and graft function. This case underlines the importance of early recognition and timely surgical intervention in giant aortic root aneurysms. Although the Bentall procedure is routinely performed worldwide, the surgical management of giant aneurysms >10 cm remains technically complex and underreported. Preoperative planning, alternative cannulation strategies, and meticulous surgical technique are crucial for safe and effective management of these high-risk cases.

Keywords: aortic rupture; aortic valve regurgitation; ascending aortic aneurysm; bentall procedure; emergency aortic surgery; giant aortic root; valve replacement.

Figure 1. Preoperative CT images of the giant aortic root aneurysm. (A) Axial cross-sectional view demonstrating a massive aneurysmal dilation of the aortic root, measuring over 10 cm in diameter, compressing adjacent mediastinal structures. (B) Sagittal reconstruction highlighting the full extent of the aortic root dilation, with preserved continuity of the ascending aorta and absence of dissection or rupture.

Figure 2. Intraoperative photographs of the surgical procedure. (A) Suturing of the mechanical valved conduit (Carboseal Valsalva graft) to the native aortic annulus. (B) Precise placement of the prosthetic conduit within the aortic root following resection of the aneurysm. (C) Reimplantation of the mobilized coronary artery buttons into the conduit using end-to-side anastomoses. (D) Final view demonstrating the completed Bentall procedure with successful graft placement and coronary reimplantation.