Management of Acute Type B Aortic Dissection.

Acute type B aortic dissection (TBAD) remains a high-stakes emergency. The New England Journal of Medicine review by Mussa and Kougias synthesizes contemporary evidence and guidelines into a pragmatic pathway. Key points include: initial anti-impulse therapy with IV beta-blockers targeting SBP 100–120 mmHg and HR 60–80 bpm; TEVAR as the preferred modality for complicated TBAD (rupture or end-organ malperfusion); and structured, lifelong surveillance after discharge (imaging at 1, 6, and 12 months, then annually).

Classification anchors decision-making: Stanford type B dissections originate distal to the left subclavian artery (SVS–STS zones ≥2), with most uncomplicated TBADs initially managed medically and 60% presenting without rupture/malperfusion.

When complications arise (rupture or malperfusion syndromes—often dynamic branch obstruction), urgent endovascular repair to cover the proximal entry tear is recommended; adjuncts (carotid–subclavian bypass or branched endografts) may preserve subclavian flow. Open repair is reserved for unfavorable anatomy or persistent malperfusion post-TEVAR.

For “uncomplicated but high-risk” TBAD (e.g., total aortic diameter >4 cm, false lumen >22 mm, entry tear >1 cm, refractory pain/hypertension, bloody pleural effusion), early TEVAR is considered but remains based on limited data; ongoing randomized trials (IMPROVE-AD, SUNDAY, EARNEST) aim to clarify indications and timing.

Randomized evidence (INSTEAD/INSTEAD-XL; ADSORB) suggests TEVAR promotes aortic remodeling and may reduce late aorta-specific mortality and progression versus medical therapy alone, but with no early survival advantage—reinforcing careful selection and avoidance of very early (<48 h) intervention to reduce retrograde type A risk.

Finally, special populations warrant nuance: genetically triggered aortopathies generally favor medical therapy for uncomplicated TBAD and open repair when complicated (TEVAR mainly as a bridge); pregnancy calls for labetalol-based medical control when uncomplicated and standard emergency intervention when complicated.

#aorticdissection #TEVAR #vascularsurgery #cardiology #hypertension

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