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intervention, reducing mortality rates to 25%–27%, compared with 76% with medical management alone.1255,1276 Close monitoring and rapid intervention are essential to achieve optimal outcomes and minimize the risk of permanent neurological damage. A recommended algorithm for malperfusion management is displayed in Figure 34.

Endovascular treatment in type A aortic dissection Endovascular therapy alone has been attempted in highly selected cases and the concept of a single endovascular valve-carrying conduit was suggested recently but has not yet been validated.1281,1282 Treatment in non-A non-B aortic dissection Conservative management leads to high mortality (malperfusion, aortic rupture); thus, surgery or endovascular therapy is favoured within 14 days of symptom onset. For complicated non-A non-B aortic dissection with an arch tear, consider FET repair, though if feasible, stent-graft implantation for primary tear coverage is an alternative.1179,1283

9.3.1.4.3. Acute type B aortic dissection interventional treatment. Acute TBAD presents without complications (uncomplicated) in around 50% of cases.1250 Complicated acute TBAD includes aortic rupture, malperfusion-related issues, rapid aortic expansion, paraplegia/ paraparesis, aortic haematoma, refractory pain, and hypertension despite optimal therapy, which associates with an approximately 50% mortality risk with conservative treatment.1193,1250,1284,1285 Open surgery used to be the sole option for complicated acute TBAD but carried a mortality rate of 25%–50%. Consequently, medical management, now considered the standard for uncomplicated cases, significantly reduces mortality. Goals include lowering SBP and heart rate with BBs (see Section 9.3.1.4.1). However, adherence is the main limitation of chronic medical treatment, with a rate below 50%.1286,1287 Compliance increases with previous aortic surgery, severity of hypertension, and understanding of the disease process. Thus, surveillance and disease awareness are imperative for these patients.

Endovascular therapy for complicated acute TBAD is now the firstline treatment, provided there is favourable anatomy, due to positive short- and long-term outcomes.1288–1294 Open surgery is reserved for unsuitable cases, and fenestration could be considered as an ultima ratio. In selected instances, correcting side branch compression before proximal sealing may be considered.136 In recent years, the ADSORB (Acute Dissection Stentgraft OR Best Medical Treatment) and INSTEAD-XL (Investigation of Stent Grafts in Aortic Dissection with extended length of follow-up) trials1219,1226,1295 have reported that early intervention for uncomplicated acute and subacute TBAD is beneficial compared with medical management, and there is important debate on whether to treat patients with uncomplicated acute TBAD to improve their life expectancy.1296–1298 Intervention is considered early within 90 days after onset of symptoms and may be safer when performed in the subacute phase (>14 days after onset of symptoms), but data are scarce.1298–1300 The Society of Thoracic Surgeons/ American Association for Thoracic Surgery (STS/AATS) 2022 guidelines1294 state that prophylactic TEVAR may be considered also in patients with suitable anatomy and high-risk features (Figure 33) to reduce late aortic-related adverse events. However, this matter is not entirely settled, and the Improving outcomes in vascular disease—aortic dissection (IMPROVE-AD trial) is currently underway. This trial aims to evaluate clinical outcomes in patients with subacute (from 48 h to 6 weeks) uncomplicated type B aortic dissection (uTBAD), comparing upfront TEVAR plus medical therapy against medical therapy with surveillance for deterioration. Aortic characteristics change over time, and endovascular treatment in the chronic phase offers limited potential for aortic remodelling. Identifying specific characteristics at the time of acute TBAD diagnosis that predict a complicated course has been attempted. Independent predictors of TBAD outcomes include a primary entry tear >10 mm located at the inner aortic curvature,1301 initial aortic diameter >40 mm,1301,1302 initial FL diameter >20 mm,1301 number/size of fenestrations between the true lumen and FL,1303 stent graft-induced new entry tear,1304,1305 and partial FL thrombosis.1306,1307 These parameters are summarized in a new system for the categorization of AD, DISSECT (Duration from onset of symptoms, Intimal tear location, Size of the aorta based on maximum trans-aortic diameter, Segmental Extent, Clinical complications related to the dissection, Thrombosis of the FL),1308 which serves as a guide to support a therapeutic decision (Figure 33).1308 A recent meta-analysis found TEVAR to be superior to best medical therapy in uncomplicated acute TBAD. Early outcomes were similar, but TEVAR was associated with fewer long-term events and better aortic remodelling.1297,1298,1309 Thus, in stable TBAD with suitable anatomy and high-risk features, pre-emptive TEVAR to improve the late outcome should be considered. Accurate endograft sizing is vital for TEVAR success, as errors may lead to complications. Disease-specific factors, such as acute thoracic aortic syndromes, pose challenges due to fluctuations in aorta diameter from haemorrhagic shock and resuscitation. Sizing decisions must account for these changes. Measuring the thoracic aorta based on admission CCT may be imprecise, even with proper centreline measurements. Real-time imaging, especially IVUS, enhances accuracy, particularly in hypovolaemic cases. However, further research is required to clarify the role of intraoperative imaging methods (e.g. IVUS, TOE, 3D CCT) in endograft sizing and long-term outcomes for optimal patient care.194

Recommendation Table 48 — Recommendations for the management of malperfusion in the setting of acute aortic dissection

Recommendations Classa Levelb

In patients with acute TAAD presenting with malperfusion (cerebral, mesenteric, lower limb, or renal), immediate aortic surgery is recommended.1275,1277 I B In patients with acute TAAD presenting with cerebral malperfusion or non-haemorrhagic stroke, immediate aortic surgery should be considered to improve neurological outcome and reduce mortality.1255,1276,1278 IIa B In patients with acute TAAD presenting with clinically significant mesenteric malperfusion syndrome, immediate invasive angiographic diagnostics to evaluate percutaneous malperfusion repair before or directly after aortic surgery, in aortic centres with expertise, should be considered.1278–1280 IIa C © ESC 2024

TAAD, type A aortic dissection. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/45/36/3538/7738955 by guest on 07 October 2026