TEVAR vs Standard Medical Therapy in Uncomplicated Type B Aortic Dissection: A Roundtable with the IMPROVE-AD, EARNEST and SUNDAY Trial Investigators

Three trials walk into an aorta and ask what the house recommends. The bartender shrugs: “Sorry, we’re randomising tonight.”

Three trials. Three leading investigators. One of the biggest unresolved questions in aortic surgery: should patients with uncomplicated type B aortic dissection undergo thoracic endovascular aortic repair (TEVAR), or is best medical therapy the better strategy?

In this episode of the ESVS Podcast, Safa Riahi brings together Professor Jacob Budtz-Lilly (SUNDAY), Professor Firas Mussa (IMPROVE-AD) and Professor Colin Bicknell (EARNEST), for an in-depth roundtable exploring the rationale, design, and challenges behind three major randomised controlled trials. From differences in patient selection and timing of intervention to aortic remodelling, procedural safety, long-term outcomes, and cost-effectiveness, we examine what each trial hopes to establish and why their results could reshape the management of uncomplicated type B aortic dissection.

We also discuss the meaning of “uncomplicated,” the limitations of our current evidence, the importance of best medical therapy, and the challenge of communicating genuine clinical uncertainty to patients. Will these trials finally help us identify who benefits from early TEVAR, when to intervene, and whether improved aortic remodelling translates into better outcomes for patients?

Three trials walk into an aorta. The answers, for now, remain anything but straightforward.

With: Professor Firas Mussa, Professor Colin Bicknell, and Professor Jacob Budtz-Lilly.

Trials discussed:

• IMPROVE-AD: https://clinicaltrials.gov/study/NCT06087029
• EARNEST: https://www.isrctn.com/ISRCTN30838068
• SUNDAY: https://clinicaltrials.gov/study/NCT05215587