TEVAR for Nontraumatic Ruptured Type B Aortic Dissections: A European Multicentre Study.

OBJECTIVE: Ruptured acute type B aortic dissection (TBAD) is rare, carries high mortality risk, and presents major challenges with limited supporting evidence. This study evaluated early and mid-term outcomes after thoracic endovascular aortic repair (TEVAR) for nontraumatic ruptured TBAD. METHODS: This retrospective multicentre study included patients undergoing TEVAR for nontraumatic ruptured TBAD at 6 vascular centres (2010-2023). Rupture was defined as haemothorax (30-45 HU) on preoperative computed tomography with or without aortic wall disruption or active extravasation. Outcomes were 30-day and mid-term mortality, reinterventions, and complications. RESULTS: Thirty-four patients treated with TEVAR for nontraumatic ruptured TBAD were identified; 11 haemodynamically unstable. Distal dissection extended to Lombardi zone ≤5 in 12 (35.3%), and ≥6 in 22 (64.7%), and distal landing zone was within dissected aorta in 20 (58.8%). Visceral branch revascularisation and intentional coverage of the left subclavian artery were performed in 14 (41.2%) and 15 (44.1%) patients, respectively. Median follow-up for those surviving the first 30-day period was 17.5 months (interquartile range [IQR] 4.75-39.5). Thirty-day mortality was 20.6% (n = 7) and 90-day mortality 35.3% (n = 12). At 3-year follow-up, 14 patients (41.2%) had died, of which 8 patients suffered an aortic-related death. No difference in survival between distal TEVAR landing in non-dissected versus dissected aorta (42.9% vs 57.1%; log-rank P = .738) was observed. Seven patients had aortic reinterventions (20.6%). CONCLUSION: In this multicentre cohort of ruptured TBAD treated with TEVAR, the perioperative mortality at 90 days was high, but patients surviving that period had an acceptable mid-term outcome. These findings suggests that strict healthy-to-healthy landing may not always be necessary when rapid haemorrhage control is required in ruptured TBAD. Prospective registries and international collaborative studies are needed to refine patient selection, treatment strategies and long-term outcomes.Clinical ImpactEvidence regarding TEVAR for ruptured TBAD remains limited. The present multicentre study therefore provides valuable new insights with real-world outcomes across multiple vascular institutions. The findings suggests that strict healthy-to-healthy landing may not always be necessary when rapid haemorrhage control should be prioritized in ruptured TBAD.TEVAR remains the primary treatment for ruptured TBAD, but perioperative risk is substantial, with a 90-day mortality of 35%. Clinicians should recognize that patients surviving this critical early window have acceptable mid-term outcomes, supporting continued aggressive intervention despite the early risk. In this study distal landing within dissected aorta does not compromise survival compared to healthy-to-healthy landing, challenging conventional anatomical dogma. This finding gives clinicians flexibility to prioritize rapid haemorrhage control over strict landing-zone criteria during emergent repair, particularly when unstable anatomy limits ideal distal fixation, without sacrificing longer-term survival benefit.