At the 2026 European Vascular Course (EVC; 8–10 March, Maastricht, Netherlands), Bijan Modarai (King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London, UK) addressed the nuances involved in management of subacute type B aortic dissection.
Focusing on the theme of refining patient selection and therapeutic approach, Modarai emphasised that management decisions pertaining to patients presenting with ‘uncomplicated’ subacute type B dissection remain fundamentally limited by an incomplete understanding of disease heterogeneity. He began by outlining the current framework, in which patients who present unequivocally with a complicated type B dissection are treated with thoracic endovascular aortic repair (TEVAR), while those without these features are generally managed medically. He highlighted, however, that this distinction is increasingly being challenged. “Up to 75% of acute type B dissections are labelled uncomplicated, yet a substantial proportion will go on to require late intervention,” Modarai noted, pointing to the persistent gap between early classification and long-term outcomes. This, he argued, reflects the limitations of a binary classification system that does not adequately account for the heterogeneity of the disease.
A key focus of the presentation was the subacute phase, typically defined as 15–90 days, which Modarai described as a critical but poorly understood therapeutic window. Rather than representing a uniform stage, this period encompasses a spectrum of biological states, ranging from fragile aortic tissue prone to progression, to more stable phenotypes with reduced remodelling potential. Modarai also drew attention to several areas of ongoing controversy. While all guidelines support medical management for uncomplicated dissections, some also allow for consideration of early endovascular repair in selected high-risk patients. However, he stressed that the criteria for defining ‘high risk’ are not robust, and important clinical parameters, such as refractory pain and hypertension, lack clear thresholds or standardised definitions. He cautioned against the indiscriminate use of TEVAR, highlighting procedure-related risks including stroke, spinal cord ischaemia, and retrograde dissection. “The question is not whether TEVAR works, it does, but rather in whom and when it should be applied,” he said. There was reference to the recently published European Society for Vascular Surgery (ESVS) 2026 clinical practice guidelines on the management of descending thoracic and thoracoabdominal aortic diseases, which emphasise that, in the absence of robust evidence, TEVAR should not be performed for this indication outside of clinical trials.
Looking ahead, Modarai pointed to the potential of precision medicine approaches to address these challenges. He suggested that the integration of advanced imaging, computational modelling, and large-scale clinical datasets could enable more accurate prediction of disease progression and support more individualised treatment strategies. Ongoing randomised trials are expected to provide further clarity in due course, but he emphasised that significant evidence gaps currently remain.
Speaking to Vascular News at EVC 2026, Modarai remarked that his presentation “underscored why aortic dissection continues to attract intense interest within the vascular community. It is a condition that lends itself to personalised care, yet remains characterised by uncertainty, variation in practice, and unresolved clinical questions.”
He noted that these themes will form the focus of the upcoming third Interdisciplinary Aortic Dissection Symposium (IADS; 10 September, London, UK). “Building on two previous meetings, the symposium aims to bring together an international, multidisciplinary faculty spanning vascular and cardiothoracic surgery, cardiology, radiology, and translational science,” he shared. “The programme will focus on controversial areas in dissection management and emerging endovascular and adjunctive techniques.”
