The treatment strategy for acute type A aortic dissection consists of entry closure and maximal resection of the dissected aortic segment. In cases where the entry is located in the distal descending aorta, as in this case, entry closure is challenging, and surgery often involves only maximal resection of the dissected segment. The patient was a 53-year-old man who presented with sudden onset of chest pain. CT revealed a retrograde Stanford type A acute aortic dissection with a tear in the distal descending aorta. Preoperative measurements suggested that entry closure using frozen elephant trunk (FET) would be impossible. Surgery was performed with the goal of maximal resection of the dissected aortic segment in a hybrid operating room. The patient underwent total arch replacement (TAR) using FET. TEE revealed true lumen stenosis beyond the descending aorta, along with a decrease in lower limb blood pressure reducing blood flow to the abdominal branches. Therefore, emergency TEVAR was performed to achieve entry closure in the entire descending aorta. After TEVAR, the true lumen expanded, and perfusion to the lower limbs and abdominal branches improved. The postoperative course was uneventful, and the patient was discharged on postoperative day 10.

Background: and Purpose Differences in measurement of the extent of acute ischemic stroke using the Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) by non-contrast computed tomography (CT-ASPECTS stratum) and diffusion-weighted imaging (DWI-ASPECTS stratum) may impact the efficacy of endovascular therapy (EVT) in patients with a large ischemic core. Methods: The RESCUE-Japan LIMIT (Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism Japan–Large IscheMIc core Trial) was a multicenter, open-label, randomized clinical trial that evaluated the efficacy and safety of EVT in patients with ASPECTS of 3–5. CT-ASPECTS was prioritized when both CT-ASPECTS and DWI-ASPECTS were measured. The effects of EVT on the modified Rankin Scale (mRS) score at 90 days were assessed separately for each stratum. Results: Among 183 patients, 112 (EVT group, 53; No-EVT group, 59) were in the CT-ASPECTS stratum and 71 (EVT group, 40; No-EVT group, 31) in the DWI-ASPECTS stratum. The common odds ratio (OR) (95% confidence interval) of the EVT group for one scale shift of the mRS score toward 0 was 1.29 (0.65–2.54) compared to the No-EVT group in CT-ASPECTS stratum, and 6.15 (2.46–16.3) in DWI-ASPECTS stratum with significant interaction between treatment assignment and mode of imaging study (P=0.002). There were significant interactions in the improvement of the National Institutes of Health Stroke Scale score at 48 hours (CT-ASPECTS stratum: OR, 1.95; DWIASPECTS stratum: OR, 14.5; interaction P=0.035) and mortality at 90 days (CT-ASPECTS stratum: OR, 2.07; DWI-ASPECTS stratum: OR, 0.23; interaction P=0.008). Conclusion Patients with ASPECTS of 3–5 on MRI benefitted more from EVT than those with ASPECTS of 3–5 on CT.