Perspectives on Thoracic Endovascular Aortic Repair for Uncomplicated Type B Aortic Dissection: An International Survey Within the SUNDAY Network

Background: Thoracic endovascular aortic repair (TEVAR) is increasingly considered in selected patients with uncomplicated type B aortic dissection (uTBAD), but uncertainty remains regarding indications for intervention and treatment strategies. This study aimed to explore potential variation in TEVAR indications and treatment strategies for uTBAD among principal investigators (PIs) of the Scandinavian trial of Uncomplicated Aortic Dissection Therapy (SUNDAY). Methods: A prospective, cross-sectional, questionnaire-based study was conducted among PIs of the SUNDAY trial network. A structured survey was developed by the first and last author using contemporary guidelines and relevant literature and was subsequently reviewed by all co-authors. The questionnaire addressed three topics: definitions, TEVAR indications, and treatment strategies. Data were collected via Castor and analyzed using SPSS version 29.0. A center-weighted sensitivity analysis and within-center concordance analysis were performed to account for multiple respondents from the same center. Results: The response rate was 78.2% (43/55 PIs), representing 31 centers. The presence or development of complications was the main driver for TEVAR (37/43, 86.0%). Rupture (43/43, 100%), clinical signs of malperfusion (43/43, 100%), and rapid aortic expansion (38/43, 88.4%) were consistently considered indications for TEVAR, whereas more variation was observed for refractory pain (28/43, 65.1%) and refractory hypertension (26/43, 60.5%). Interpretation of high-risk imaging features varied, with 37.2% (16/43) considering multiple features an indication for TEVAR. Procedural strategies varied, with spot stenting selected by 58.1% (25/43) of respondents, although more extensive aortic coverage was also reported. Landing zone characteristics and oversizing preferences were more consistent, with 79.1% (34/43) defining a healthy landing zone by the absence of intramural hematoma or dissection, 58.1% (25/43) preferring a landing zone length of 2 cm, and 51.2% (22/43) preferring 10% stent graft oversizing. Center-weighted sensitivity analyses showed generally similar estimates, whereas within-center concordance varied across items (range 20–100%), with complete agreement for 8 of 50 items. Conclusions: Among SUNDAY PIs, there was broad agreement regarding the distinction between uncomplicated and complicated type B aortic dissection (TBAD) and the role of TEVAR in the presence of complications, whereas variation remained in the interpretation of high-risk imaging features and procedural strategies. These findings highlight variation in decision-making regarding the management of uTBAD within the SUNDAY network and support the need for prospective evidence to guide TEVAR decision-making.