We report the case of a patient who developed an acute Stanford type B aortic dissection 4 days after thoracoabdominal branch endoprosthesis repair for a ruptured thoracoabdominal aortic aneurysm. The dissection caused complete endograft collapse and profound malperfusion. Emergent salvage endovascular repair successfully re-expanded the graft; however, the patient ultimately died because of the severity of the systemic injuries. This case highlights the potential for acute type B aortic dissection to occur in a recently stented thoracic aorta segment following thoracoabdominal branch endoprosthesis repair and emphasizes the need for urgent recognition of malperfusion and meticulous computed tomography evaluation of the aortic injury pattern.

Short common iliac artery anatomy may preclude iliac branch device use during fenestrated or branched aortic repair. We describe two patients treated with a low-profile, short-tip distal branched custom-made device based on an aortouni-iliac configuration and combined with fenestrated or branched repair. The device incorporated iliac side branches to preserve bilateral internal iliac artery perfusion. In aneurysmal anatomy, complete release caused loss of ipsilateral branch access, requiring through-and-through control and balloon-assisted luminal modulation. In chronic dissection, staggered release preserved a working lumen but required adjunctive balloon dilatation. Device configuration, orientation, luminal constraint, and release sequence were critical to technical success.

Severe perivisceral aortic thrombus is a rare cause of embolic organ dysfunction with limited treatment guidance. We report a 70-year-old woman with progressive renal failure due to extensive perivisceral and renal artery thrombus. Given high embolic risk, endovascular therapy was deferred, and open aortic endarterectomy was performed. Persistent renal artery compromise necessitated intraoperative conversion to extra-anatomic thoracobirenal bypass. Postoperatively, renal function normalized with durable graft patency at 1 year. A concomitant descending thoracic aortic dissection was managed conservatively. This case highlights the limitations of endovascular therapy in extensive aortic thrombus and supports individualized open revascularization strategies in select patients.

Aortic dissection is a life-threatening cardiovascular emergency characterized by rapid progression and high mortality. Although medial degeneration is a key pathological feature of aortic dissection, the mechanisms that drive aortic wall instability remain incompletely understood. Aortic calcification is a pathological mineralization process that can alter vascular structure and function, but its role in aortic dissection has received limited attention. Here we show that tissue nonspecific alkaline phosphatase associated calcium phosphate microdeposition is linked to aortic medial degeneration and dissection susceptibility. Human aortic dissection tissues and diseased mouse aortas show increased mineralization together with elevated tissue nonspecific alkaline phosphatase activity. Calcium phosphate deposits promote vascular smooth muscle cell phenotypic switching and inflammatory remodeling, while tissue nonspecific alkaline phosphatase facilitates mineral deposition under permissive conditions. Reducing tissue nonspecific alkaline phosphatase activity or expression attenuates aortic calcium phosphate deposition, medial degeneration and dissection in mice. These findings identify tissue nonspecific alkaline phosphatase associated microdeposition as a mechanism contributing to aortic wall vulnerability.

Accurate identification of aortic dissection (AD) in emergencies is clinically critical. Non-contrast CT (NC-CT), the standard emergency imaging for chest pain, has limited AD diagnostic sensitivity. We developed an anatomy prior-driven multimodal contrastive learning framework, extracting discriminative features from contrast-enhanced CT (CE-CT) and radiological reports to enhance NC-CT-based AD detection. Aortic segmentation and straightening focus analysis on relevant anatomy, while our tri-encoder architecture leverages Fourier cross-attention (core innovation) to co-extract spatial and frequency-domain features with hybrid contrastive-focal frequency loss. After pre-training, only NC-CT is needed for inference. Evaluated on 134 subjects (70 AD, 64 non-AD), our method achieved 0.955 accuracy and 0.983 AUC, outperforming 9 SOTA models. External validation showed 0.933 accuracy, with lumen segmentation reaching an average Dice score of 0.773. These results demonstrate that our method can advance AD detection and enable accurate true/false lumen localization using NC-CT alone.

Aneurysms of the pancreaticoduodenal arcade are uncommon visceral artery aneurysms that are strongly associated with stenosis or occlusion of the celiac axis and that may rupture irrespective of size. Rupture produces a peripancreatic or retroperitoneal hematoma, and duodenal stenosis is a recognized sequela; biliary complications have rarely been reported. An 84-year-old man admitted with an acute Stanford type B aortic dissection with a thrombosed false lumen was managed conservatively with strict blood pressure control. Surveillance non-contrast computed tomography (CT) on day 7 incidentally showed a periduodenal hematoma, absent on day 5, in a patient who had no abdominal pain. Contrast-enhanced CT on day 8 demonstrated a 5-mm aneurysm of the anterior inferior pancreaticoduodenal artery (AIPDA) adjacent to the hematoma, together with severe celiac origin stenosis. The same narrowing was present on the day 0 study, as demonstrated on retrospective review. Coil embolization on day 12 occluded the aneurysm, and the arcade remained patent, maintaining collateral blood flow to the liver; the celiac origin stenosis was not treated. Postprandial vomiting began on day 16, and imaging on day 19 confirmed high-grade stenosis at the distal descending duodenum. He was managed with nasogastric decompression and parenteral nutrition, and endoscopy showed a short, tight stenosis of extrinsic appearance with normal mucosa. On day 37, he developed septic shock with direct-predominant hyperbilirubinemia, and CT showed a dilated biliary tree with severe narrowing of the common bile duct at the level of the coils. According to the Tokyo Guidelines 2018, grade III acute cholangitis was diagnosed, and an endoscopic nasobiliary drainage catheter was placed without sphincterotomy; blood and bile grew extended-spectrum beta-lactamase-producing Escherichia coli. The duodenal stenosis improved sufficiently for an oral elemental diet on day 45 and a full oral diet on day 47, and he was discharged home walking unaided on day 60. Rupture of an AIPDA aneurysm may be painless, although this is not the usual presentation, and may be detected only on surveillance imaging; severe cholangitis may follow in a patient with a persistent periduodenal hematoma and duodenal obstruction. Both complications were managed nonoperatively.

Thoracic endovascular aortic repair (TEVAR) for acute type B aortic dissection can be complicated by retrograde type A aortic dissection (RTAD) and stent graft-induced new entry (SINE). A 77-year-old man developed acute type A aortic dissection after TEVAR and subsequently experienced recurrent RTAD and 3 episodes of distal SINE despite multiple surgical and endovascular interventions, eventually dying of postoperative bleeding. This case highlights the potential for repeated RTAD and SINE in the same patient and underscores the importance of careful surgical planning and endovascular device selection in patients with fragile, tortuous dissected aortas.

Radical cystectomy with pelvic lymph node dissection remains the standard of care for muscle-invasive and high-risk nonmuscle-invasive bladder cancer. Lymphatic mapping studies demonstrate that primary drainage traverses the true pelvis, with most metastatic nodes located below the aortic bifurcation. Two randomized trials failed to show a survival benefit from extended dissection, though both were limited by enrolment of lower-risk populations and underpowered to detect true treatment effects. A risk-adapted approach is recommended, reserving extended dissection for higher-risk patients while recognizing that a subset of node-positive patients can achieve long-term disease-free survival with surgery alone.