Long-Term Outcomes of Risk Stratification–Guided Preemptive Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection

Background The role of preemptive thoracic endovascular aortic repair (TEVAR) in uncomplicated type B aortic dissection (TBAD) remains debated, and long-term outcome data from real-world cohorts are limited. We evaluated the safety and long-term effectiveness of risk stratification–guided preemptive TEVAR within a comprehensive aortic management strategy. Methods Among 473 consecutive patients with acute type B aortic dissection treated at multiple centers between 2004 and 2026, 351 patients who successfully completed acute-phase best medical therapy were included. Preemptive TEVAR was selectively performed in patients considered at high risk for late aortic events. Propensity score matching was performed using age, sex, hypertension, maximal aortic diameter in the early subacute phase, patent false lumen, and false lumen diameter in the early subacute phase, resulting in 52 matched pairs. Long-term aortic outcomes were evaluated using Kaplan–Meier analysis and Cox proportional hazards models. Results Patients undergoing preemptive TEVAR exhibited unfavorable aortic morphology during follow-up, including narrower true lumen and enlarged false lumen. After preemptive TEVAR, all patients achieved partial or complete false lumen thrombosis with favorable aortic remodeling, resulting in significant reduction of aortic diameter to levels comparable with the non-preemptive group at 12 months. In the propensity-matched cohort, freedom from aortic adverse events at 10 and 13 years was 95.7% and 82.0% in the preemptive TEVAR group versus 70.1% and 70.1% in the non-preemptive group (P=0.008). No aortic-related deaths occurred after preemptive TEVAR. Multivariable analysis identified age and narrow true lumen as independent predictors of aortic adverse events. Conclusions Risk stratification–guided preemptive TEVAR was safe and associated with durable aortic remodeling without excess late mortality in selected patients with uncomplicated TBAD. These findings suggest that a selective risk stratification–guided approach to preemptive TEVAR may contribute to favorable aortic remodeling; however, its impact on long-term clinical benefit remains uncertain.