Clinical Summary A 25-year-old male car driver sustained multiple injuries in a road traffic crash, including hepatic laceration, aortic transection, and right humeral and femoral fractures. He underwent emergency laparotomy and partial hepatectomy. A subsequent aortogram revealed a pseudoaneurysm distal to the left subclavian artery. Repair of the transected aorta was performed with the proximal descending aorta replaced with an 18-mm woven Dacron graft through a left thoracotomy. Recovery was complicated by methicillin-resistant Staphylococcus aureus (MRSA) infection of a large sacral sore, which required a rotation flap, and bilateral MRSA empyema, which was managed with Cope loop drainage and 6 months of intravenous vancomycin. Three years later, the patient returned with hemoptysis. Computed tomographic scan and aortogram demonstrated leakage from the distal end of the aortic graft resulting in a pseudoaneurysm and an aortobronchial fistula. Endoluminal stenting with a 22 mm 131 mm Talent LPS stent graft (Medtronic AVE, Santa Rosa, Calif) was performed with successful occlusion of the leak. MRSA septicemia developed in the patient after the procedure, and he was treated with intravenous vancomycin and subsequently with intramuscular teicoplanin. Two years later, the patient returned with a 2-month history of hemoptysis. Computed tomographic scan of the thorax was suggestive of a recurrent leak, which was confirmed on aortogram (Figure 1). Emergency extra-anatomic ascending aorta–to–descending aorta bypass was performed with exclusion of the proximal descending thoracic aorta from which the leak arose. This was performed through a median sternotomy on full cardiopulmonary bypass via ascending aortic and right atrial cannulation. With the empty heart displaced superiorly, the distal descending aorta was accessed through a longitudinal incision in the posterior pericardium. A 16-mm woven Dacron graft was anastomosed to the distal descending thoracic aorta with a side-biting clamp. The graft was tracked posterior to the inferior vena cava and anastomosed to the right lateral aspect of the ascending aorta (Figure 2). The descending aorta between the left subclavian artery and the new distal anastomosis was excluded. At the end of surgery, the heart was edematous; the chest was closed 5 days later. Hemoptysis settled, and the patient made a satisfactory recovery. In view of the patient’s life-threatening complications from MRSA infection to the prosthetic grafts, he is on lifelong antiMRSA treatment. He has remained well for the past 2 years.