A 75-year-old man presented to the emergency department with nonspecific abdominal pain and a markedly poor general condition. He had a recent history of Bentall–De Bono aortic valve replacement and had been discharged <72 h earlier. In the setting of hemodynamic instability with hyperlactatemic metabolic acidosis (lactate > 10 mmol/L), intensive resuscitation was initiated, and an emergency abdominal computed tomography angiography (CTA) was performed. The study demonstrated contrast extravasation from the tubular aortic segment consistent with an endoleak (Fig. 1), along with extensive portal pneumatosis (intraluminal air in the superior mesenteric vein, splenoportal axis, and portal vein) (Fig. 2), corresponding to massive intestinal ischemia (Fig. 3). The patient’s condition deteriorated, and he died within the following hours.

Figure 1

Figure 2

Figure 3