Type B aortic dissection (TBAD) currently represents one of the most demanding scenarios in cardiovascular surgical practice due to its clinical heterogeneity and the complexity of therapeutic decision-making. Over recent decades, endovascular therapy has emerged as a highly valuable modality, substantially broadening the spectrum of management beyond exclusive medical treatment or conventional open repair. Nevertheless, this strategy is not without limitations, particularly in young individuals, in whom long life expectancy, device durability, and the cumulative risk of reintervention play a decisive role in defining the optimal approach.

In this context, Yildiz et al. reported the largest multicentre study to date exclusively addressing patients aged ≤30 years with invasively treated TBAD. The objective was to characterize the underlying aetiology and clinical outcomes in this highly selected population, with particular emphasis on the impact of heritable thoracic aortic disease (HTAD).

A retrospective analysis was conducted across 19 international aortic centres, including 139 patients, primarily presenting with acute or subacute TBAD. Overall, 57% of the cohort had a diagnosis of HTAD, most frequently Marfan syndrome, whereas arterial hypertension was documented in only approximately one-third of cases. Most patients initially presented with uncomplicated TBAD, although a substantial proportion required TEVAR or open repair during follow-up.

Early mortality was low, and mid-term survival was excellent. No significant survival differences were observed between complicated and uncomplicated TBAD or between open and endovascular strategies. However, HTAD was independently associated with a higher risk of recurrent aortic reintervention (HR 3.3; p = .004).

The authors conclude that TBAD in young patients occurs predominantly in the setting of genetically mediated aortic wall disease. Although both open surgery and TEVAR provide highly favourable early and mid-term results, patients with HTAD represent a high-risk subgroup for subsequent aortic procedures. These findings underscore the importance of lifelong surveillance and meticulous initial treatment selection in this age group.

COMMENTARY:

One of the most thought-provoking aspects of the Yildiz et al. series is the direct comparison between TEVAR and conventional open surgery. Contemporary clinical reasoning often favours a percutaneous strategy because of its lower immediate invasiveness and faster recovery—particularly appealing in the acute aortic setting. However, this analysis compels us to reconsider this paradigm in very young patients. When performed in experienced centres, both approaches demonstrated excellent and comparable mid-term survival. This observation shifts the focus away from perioperative mortality as the primary determinant and redirects attention toward long-term durability.

The critical issue emerges when examining the long-term interaction between a rigid endovascular prosthesis and a genetically fragile aortic wall. In a cohort where nearly 60% of patients have HTAD, the radial force exerted by stent grafts on structurally compromised tissue may represent the Achilles’ heel of the endovascular strategy. Although TEVAR effectively addresses the acute event, the presence of genetically mediated arteriopathy was an independent predictor of reintervention. For many of these patients, TEVAR may therefore function as a temporizing solution rather than a definitive repair, potentially transforming the disease into a chronic condition requiring continuous surveillance.

Consequently, disease burden in this population should not be evaluated solely by survival metrics but also by cumulative morbidity: repeated imaging, radiation exposure, progressive technical complexity of reinterventions, and the psychological impact of lifelong follow-up. The key lesson from this multicentre experience is that the “minimal invasiveness” of catheter-based therapy may paradoxically translate into “maximal healthcare dependency” over time. In young patients with suspected connective tissue disorders, open surgical repair—despite its greater initial invasiveness—may provide superior durability and long-term freedom from reintervention. This reinforces the need for individualized decision-making beyond prevailing technical trends.

REFERENCE:

Yildiz M, Luehr M, Ma WG, Martens A, Ruhparwar A, Pellenc Q, et al. Type B Aortic Dissection in Patients Aged 30 Years or Younger: A Retrospective Multicentre Study. Eur J Cardiothorac Surg. 2026;68(1):ezaf450. doi:10.1093/ejcts/ezaf450.