Since 2022, when Urokinase became unavailable in Japan, 18 consecutive patients (68±9 years old) with thrombotic lower limb arterial occlusion have been treated with catheter-directed thrombolysis (CDT) using tissue-type plasminogen activator (alteplase) at our hospital. The median duration of CDT was 1 (1–3) days. The average infusion rate of alteplase was 0.0087±0.0016 mg/kg/hr. Sixteen patients underwent additional catheter procedures, including balloon dilatation, stent implantation, and aspiration, before and after CDT. Within 30 days after the procedure, one major adverse limb event, which was a major limb amputation, developed, and BARC 3a or 3b was observed in 7 patients. On the other hand, successful recanalization, defined as TIPI 2 <, was achieved in 17 of 18 patients. CDT with alteplase appears to be an effective and relatively safe procedure for Japanese patients with thrombotic lower limb arterial occlusion.

Behçet’s disease is a relapsing inflammatory disorder driven by immune dysregulation and may involve the aorta. We report a rare case of acute Stanford type A aortic dissection in a 48-year-old man with prior intestinal Behçet’s disease. Emergency partial arch replacement was performed using a Hemashield Platinum graft with double-felt reinforcement and BioGlue for stump formation. To mitigate anastomotic pseudoaneurysm risk, postoperative inflammation was tightly controlled with corticosteroids and scheduled infliximab (Remicade) after discharge. Serial imaging over 4 years demonstrated no pseudoaneurysm. This case underscores the value of reinforced repair plus sustained immunosuppression.

The optimal management of multiple aortic aneurysms remains controversial. A 72-year-old woman underwent staged surgical repair for multiple aortic aneurysms identified following acute Stanford type B aortic dissection. Total arch replacement was first performed for the brachiocephalic artery aneurysm and thoracic aortic aneurysm. While awaiting elective repair of the abdominal aortic aneurysm, the patient developed rupture, necessitating emergency endovascular aneurysm repair (EVAR). Staged surgical management carries a risk of residual aneurysm enlargement or rupture during the waiting period, underscoring the need for careful surveillance and timely intervention.

An 18-year-old man developed superior vena cava syndrome due to a huge mediastinal malignant germ cell tumor. After chemotherapy followed by tumor resection, he underwent endovascular therapy because he had persistent face and the right arm edema and heaviness in his head, presumably due to the organized thrombotic occlusion from the superior vena cava through the right subclavian vein and the right internal jugular vein. A multi-directional approach and an IVUS-guided technique enabled restoration of blood flow without stent implantation. Since then, he has not experienced symptom recurrence exept one repeat endovascular therapy to the right subclavian vein.

An 85-year-old man with chronic Stanford type B aortic dissection showed progressive aneurysmal enlargement of the descending thoracic aorta. Because open surgical repair was considered high risk, an endovascular approach was selected. Physician-modified thoracic endovascular aortic repair (PM-TEVAR) was performed to close the proximal entry tear, and the distal false lumen was treated using the Candy Plug technique. Postoperative contrast-enhanced computed tomography demonstrated complete false lumen thrombosis with disappearance of false lumen flow. This combined strategy may be a useful option for anatomically challenging chronic TBAD cases.