The treatment strategy for acute and subacute Stanford type B aortic dissection has changed significantly since the advent of TEVAR. Indication for invasive treatment: In addition to the conventional complicated cases (rupture or malperfusion case), the indication for invasive treatment now includes cases with refractory hypertension, persistent or recurrent pain, large aortic diameter, and other conditions that are considered to have a poor prognosis with conservative treatment. Treatment methods: TEVAR is the first choice for acute, subacute, and early chronic-stage treatment, and when this is not possible, other techniques (fenestration and graft replacement) are chosen. Treatment timing: The timing of invasive treatment should be emergent in life-threatening conditions (for rupture or malperfusion case) and immediate in symptomatic cases, while in other cases, preemptive TEVAR is considered appropriate on a scheduled timing within 6 months of onset.

Patients with type B aortic dissection are treated medically unless they have fatal complications. In the acute phase of medical treatment, it is important to keep the heart rate below 60 and the systolic blood pressure below 120 mmHg. In addition, it is necessary to watch for organ ischemia and enlargement of the dissected aorta. In uncomplicated type B dissections, the early mortality rate with medical therapy is relatively low, but the 5-year mortality rate for patients alive at discharge is reported to be 12–28%. Recently, it has been shown that thoracic endovascular aortic stent graft (TEVAR) within the first year of disease onset can provide effective remodeling of dissected aorta and improve prognosis. However, because of the potential for fatal complications, TEVAR is currently recommended only for high-risk patients, who are more likely to have a poor prognosis. Various studies have been conducted to define high-risk patients and many risk factors have been reported. The future challenge is to determine the indication of preemptive TEVAR through accurate risk stratification to improve the prognosis of patients with type B aortic dissection.

Wound Bed Preparation (WBP) is a fundamental concept in the wound management of refractory ulcers. The basic concept of WBP is to remove these inhibitors (T: tissue non-viable of deficient, I: infection or inflammation, M: moisture imbalance and E: edge of wound-non advancing or undermined) and prepare the wound environment so that it is responsive to treatment. The TIME concept defines four factors (T, I, M, and E), and describes clinical interventions and their outcomes for each factor. The TIME concept is a theory that describes the clinical interventions for each factor and the results of those interventions. In the case of chronic limb threatening ischemia (CLTI), clinical intervention specific to CLTI is necessary, as clinical intervention based on the usual TIME theory alone not only delays healing but may also lead to major amputation.

Japanese guidelines on the diagnosis and treatment of aortic aneurysm and aortic dissection revised in 2020 recommends open surgical treatments for extensive chronic type B dissected aortic aneurysms (Class IIa) if the diameters of the aneurysms are over 60 mm. The current lecture demonstrates the practical surgical procedures including surgical approaches, settings of cardiopulmonary bypass, strategies of protections for spinal cord and visceral vital organs, and its short-term outcomes.

Pseudoaneurysm of the common femoral artery is a well-known complication after surgical or invasive intervention into the femoral arteries. This complication usually presents as pulsatile swelling of the groin soon after the intervention. However, we report a rare case in which a late-onset pseudoaneurysm of the left common femoral artery presented alongside lower extremity edema without swelling. An 88-year-old man presented to our clinic with left lower extremity edema but without swelling. He had previously undergone cardiac surgery that used the femoral artery for extracorporeal perfusion; during this operation, bilateral great saphenous veins were harvested as grafts for coronary artery reconstruction. After duplex ultrasound examination and enhanced computed tomography, a 50 mm pseudoaneurysm of the left common femoral artery was diagnosed (resulting from a burst suture), and surgical repair and resection of the pseudoaneurysm was performed. The entry of the pseudoaneurysm was a 6 mm-diameter defect of the arterial wall on the right side of the common femoral artery; this location was the endpoint of the suture applied in the previous surgery. The entry site was repaired using a bovine pericardium xenograft patch (XenoSure, LeMaitre Vascular, Inc., Canada). The probable reason for the rare presentation was the position of entry on the lateral wall, and the late onset was likely due to the delayed rupture of the suture in the common femoral artery. XenoSure was useful when the great saphenous vein could not be used as a biological graft. Additionally, it was adaptive and easy to manipulate during the surgery.

Iliac compression syndrome primarily occurs in the left side and is less common in the right side. We describe a case of compression of the right common iliac vein in a 54-year-old man who presented with edema, claudication of the right leg, and right groin pain. Computed tomography revealed right external iliac vein compression between the right external and iliac arteries and thrombus in the right external iliac vein. The patient received endovascular treatment with aspiration of thrombus and stenting for iliac vein. Although the stent was occluded postoperatively at 26 months, there has been no recurrence of symptoms.

A woman in her childbearing age with a large pelvic mass was referred to our department. Contrasted computed tomography revealed an oval pelvic arteriovenous malformation (PAVM) with the longest diameter of 60 mm. The PAVM had a sole tortuous arterial feeder branching from the fifth lumbar artery, and a venous outlet to the left common iliac vein (LCIV). Because of the acute branch separation angle of the lumbar artery and the distal tortuosity, the tip of the catheter could not be stabilized at the appropriate positions for embolization through the right common femoral arterial access. From the right brachial arterial (RBA) access, the X-ray opaque tip of a 0.014 inch guidewire was able to be advanced partially into the PAVM. However, the stabilization was not robust enough to support the tracking of a microcatheter or delivery sheath through the angulation before the arterial pedicle. In contrast, from the left common femoral venous (LCFV) access, the guidewire could be easily advanced into the PAVM but not into the arterial gate of the PAVM. The tip of the guidewire from the RBA was snared, and brought out through the LCFV access sheath, creating an RBA–LCFV stabilizing wire. The tip of a 6 Fr sheath could then be advanced and stabilized in the arterial pedicle sufficiently. Three self-expandable nitinol mesh devices were used to embolize the arterial pedicle and the fifth lumbar artery. After the arterial inflow embolization, the PAVM was packed coil-embolized. The final angiography confirmed the complete obliteration of PAVM, with no occurrence of post-procedural complications. The patient was discharged on the second postoperative day. She had an uneventful course of pregnancy and bore a child 18 months after the procedure. Two years after the embolization, computed tomography revealed a volume reduction of PAVM with the maximum diameter decreased to 32 mm.

Disseminated intravascular coagulation (DIC) is an infrequent dissecting aortic aneurysm complication that occurs because of chronic consumption of coagulation factors. The optimal treatment of DIC has not been established yet. A 64-year-old man developed DIC after total arch replacement for acute aortic dissection Stanford type A. Surgical treatment was a curative treatment for DIC with dissecting aortic aneurysm, but we decided to treat him medically because of the descending aortic aneurysm diameter (50 mm) and his impaired Activities of daily living (ADL). However, the administration of FFP, ATIII, and recombinant thrombomodulin only had a temporary effect on DIC. The administration of tranexamic acid stabilized the coagulative and fibrinolytic parameters and relieved bleeding tendencies with no side effects. In addition, continuous oral administration of tranexamic acid induced thrombus formation in the false lumen and reduced the aortic aneurysm diameter (46 mm). We conclude that tranexamic acid is effective for DIC associated with dissecting aortic aneurysms.

A 65-year-old woman underwent a physical examination and right hydronephrosis was noted. A CT scan revealed an inflammatory aneurysm of the right internal iliac artery and persistent sciatic artery branched from the aneurysm without aneurysmal change. The right internal iliac artery aneurysm had a maximum shorter diameter of 32 mm, which was considered a relative indication. We decided to undergo open surgery to treat hydronephrosis which was thought to be caused by the inflammation of the aneurysm. We performed aneurysmectomy, abdominal aorta to left common iliac artery and to right external iliac artery bypass with artificial graft, and right leg of the graft to the persistent sciatic artery bypass. Postoperatively, the hydronephrosis was found to be improved and the bypasses were patent without any adverse events 18 months later. Under our surveillance of past reports, there were no reports of inflammatory aortic/artery aneurysm accompanied with persistent sciatic artery, and we assumed that there seems to be no pathologic relationship between them. However, both diseases were treated in the same operative field which had several treatment option; then we presented this case of open surgery for the rare two diseases.

An 80-year-old male patient was brought to the emergency department with swelling in his right thigh and worsening anemia. A CT scan revealed that the patient had a ruptured profunda femoris artery aneurysm on the right side, as well as common iliac and internal iliac artery aneurysms on the right side and a left profunda femoris artery aneurysm. The right profunda femoris artery aneurysm was treated with endovascular procedures. After two weeks, the patient underwent EVAR (endovascular aortic repair) for the remaining common and internal iliac artery aneurysms, and a hybrid treatment for the remaining left profunda femoris artery aneurysm, which involved ligation of the aneurysm and coil embolization of the surrounding area. The patient’s postoperative course was favorable.