Surgical treatment for thoracic aortic disease has undergone a major paradigm shift over the past two decades. In particular, thoracic endovascular aortic repair (TEVAR) has rapidly gained widespread acceptance as a minimally invasive and effective treatment option for thoracic aortic aneurysms (TAA) and Stanford type B aortic dissection. Traditionally, open surgical repair with prosthetic graft replacement via thoracotomy was considered the standard treatment for these conditions; however, it was highly invasive and associated with massive intraoperative blood loss, the use of cardiopulmonary bypass, and a high incidence of postoperative complications, particularly respiratory and neurological events. Consequently, treatment selection was often challenging in elderly patients and those with significant comorbidities. The clinical application of TEVAR began in the early 2000s and was introduced into routine clinical practice in Japan following approval for national health insurance coverage in 2008. In 2009, standardized criteria for stent-graft implementation were subsequently established. Since then, the accumulation of nationwide clinical data has enabled scientific evaluation of the indications, clinical outcomes, and safety of TEVAR. In the 2020 revision of the joint guidelines on the diagnosis and management of aortic aneurysms and aortic dissection issued by the Japanese Circulation Society and the Japanese Society for Cardiovascular Surgery, TEVAR is recommended as the first-line treatment (class I) for descending thoracic aortic aneurysms when appropriate anatomical criteria are satisfied. In contrast, the application of TEVAR to aortic arch and thoracoabdominal lesions remains technically demanding, and careful consideration is required when selecting the optimal treatment strategy. This review summarizes the current status of endovascular therapy for thoracic aortic aneurysms and aortic dissection, with a focus on established indications, clinical outcomes, and contemporary treatment strategies.

A 74-year-old woman presented with hematochezia and hemodynamic instability (blood pressure: 90/60 mmHg; heart rate: 100 bpm) 23 years after living-donor kidney transplantation, followed by stabilization under conservative management. Contrast-enhanced computed tomography identified a 35-mm anastomotic pseudoaneurysm at the left external iliac artery with active retroperitoneal hemorrhage (contained rupture). The patient underwent emergency endovascular repair 18 hours after admission. A balloon-expandable stent graft (VBX) was selected due to its precise deployment capability in the presence of severe calcification and its immediate availability. Successful hemostasis was achieved, and no graft-related infection or recurrence was observed during the 1-year follow-up, despite forgoing prophylactic antibiotics in favor of rigorous clinical monitoring. This rare case illustrates that anastomotic rupture can occur even in the ultra-long-term period (>20 years) after transplantation. Prompt endovascular intervention using appropriate devices during the hemodynamically stable window is a highly effective life-saving strategy in such emergencies.