A 79 year old man had a history of ascending aortic replacement and omentopexy for tuberculous ascending aortic aneurysm rupture when he was 66 years old (Fig. 1A). He was treated for tuberculosis after surgery and had no recurrence. Thirteen years later, a pseudoaneurysm was identified on a computed tomography (CT) scan performed on routine follow up examination. Enhanced CT revealed a pseudoaneurysm arising from the side branch stump of the prosthesis (Fig. 1C and D). The pseudoaneurysm was mushroom shaped, measured 30 mm in protrusion, and had a lateral diameter of 26 mm. A thrombus was found at the tip of the pseudoaneurysm. Plain CT performed one year earlier showed no pseudoaneurysm formation (Fig. 1B). There were no findings suggestive of infection, such as fever or an increased inflammatory response. Considering his medical history, it was discerned that it would be difficult to perform repeat sternotomy, and deployment of a stent graft was considered. The ascending aortic prosthesis had a diameter of 30 mm, and the length from the proximal anastomosis to the orifice of the brachiocephalic artery was 52.6 mm on the greater curvature and 50.9 mm on the lesser curvature. The distance from the coronary artery ostia to the pseudoaneurysm was 40.6 mm. It was feasible to use the shortest thoracic endograft, although the lesser curvature was slightly shorter. The operation was performed under general anaesthesia. Following systemic heparinisation, the right inguinal region was incised, and an 8 Fr sheath was inserted via the right femoral artery (FA). Under fluoroscopy, the aortic valve was crossed with a 0.035 inch guide wire with the support of a pigtail catheter, which was subsequently exchanged for a pre-shaped Safari 2 guidewire with an extra small curve (Boston Scientific, Natick, MA, USA). A 5 Fr sheath was inserted via the right femoral vein (FV) and the left FA percutaneously. A temporary pacing catheter was inserted into the right ventricle from the right FV. A pigtail catheter was placed in the non-coronary cusp from left FA for injection of contrast. A stent graft with a diameter of 34 mm and a length of 52 mm (Valiant Navion CoveredSeal stent graft system, Medtronic, Minneapolis, MN, USA) was implanted into the ascending aorta under 180 beats/min of rapid ventricular pacing. Touch up balloon dilatation was not performed, and final angiography showed that the endograft was well positioned with no endoleaks. The rapid pacing time was 40 seconds, and the operation time was 65 minutes. A post-operative CT scan confirmed complete exclusion of the pseudoaneurysm (Fig. 1E and F).