Thoracic endovascular aortic repair in hyperacute type B aortic dissection: a mini review

Thoracic endovascular aortic repair (TEVAR) is established as the preferred treatment for many patients with complicated acute type B aortic dissection (TBAD). However, its role during the hyperacute phase (within 24 hours of symptom onset) remains controversial, as the acutely dissected aortic wall may be vulnerable to device-related injury. Nevertheless, hyperacute timing should not be regarded as an absolute contraindication to TEVAR. In patients with rupture, malperfusion, impending aortic rupture, persistent pain, refractory hypertension, or progressive true-lumen collapse, prompt entry-tear coverage can restore perfusion and prevent irreversible organ injury. Similarly, in patients without initial complications, high-risk anatomical features may help identify those who could benefit from early intervention. However, evidence supporting routine TEVAR within the first 24 hours remains limited and is predominantly observational. To ensure safe hyperacute TEVAR, careful assessment of the landing zones, conservative device sizing, avoidance of aggressive balloon molding, preservation of branch-vessel and spinal cord perfusion, and prompt recognition of retrograde type A dissection, stroke, spinal cord ischemia, and stent-graft-induced new entry are required. Ultimately, hyperacute TEVAR may be a reasonable option for selected patients with complicated TBAD, with a potential role in high-risk uncomplicated TBAD. Future prospective randomized trials integrating multimodal imaging and dynamic biomarkers are warranted to establish definitive criteria for timing and candidate selection.