Role of illicit drug use in Type B aortic dissection and trial participation

Cocaine and amphetamine use is strongly associated with Type B aortic dissection (TBAD). This disproportionately affects younger patients, who are more likely to present with complicated disease and experience greater postoperative morbidity. Stimulant-positive patients are often underrepresented or excluded from prospective trials evaluating optimal medical therapy, thoracic endovascular aortic repair, and perioperative management. Ethical concerns, medicolegal risk, stigma, and barriers to follow-up have further constrained trial participation, resulting in reliance on retrospective data and an absence of standardized management guidance. A literature review was conducted investigating the clinical presentation, medical and surgical management of stimulant-positive patients presenting with uncomplicated TBAD. We focused on anesthetic and ethical challenges unique to this population and explored the role of multidisciplinary care teams in perioperative care. Stimulant use precipitates acute sympathetic activation, labile hypertension, and increased aortic wall stress, complicating medical and procedural management. Routine stimulant screening may improve risk stratification and guide antihypertensive selection. Perioperative management should be guided by clinical evidence of intoxication rather than toxicology results. Nonurgent procedures should be deferred only in cases of active intoxication. Early multidisciplinary involvement-including addiction medicine, social work, and case management-may address barriers to medication adherence, reduce recurrence risk, and improve continuity of care. Stimulant-associated TBAD represents a distinct clinical entity requiring tailored medical, surgical, anesthetic, and psychosocial strategies. Standardized screening practices, evidence-based perioperative management, and integrated multidisciplinary care pathways may improve outcomes. Prospective studies and professional society guidance are needed to define best practices for this high-risk population.