Background:

Type-B aortic dissection (TBAD) is traditionally managed with optimal medical therapy, yet contemporary data show a survival benefit from early thoracic endovascular aortic repair (TEVAR) and emerging—but still fragmented—guidance on post-dissection exercise

prescription.

Case Synopsis:

We reported a 76-year-old woman whose extensive TBAD extended to the distal left iliac artery. She was deemed a poor surgical candidate and treated medically. On hospital day 5, she suffered sudden cardiac arrest shortly after a low-intensity cardiac rehabilitation (CR) session; autopsy suggested retrograde flap propagation triggered by exertional haemodynamic stress.

Key messages

1. Need for early endovascular intervention

a. Registry analyses demonstrate that, even in “uncomplicated” TBAD, TEVAR confers a 32 % relative reduction in long-term mortality versus medical therapyalone.

b. Our case underscores that anatomical complexity and frailty do not always preclude intervention; a proactive, multi-disciplinary evaluation can identify candidates for hybrid or limited-landing-zone techniques before catastrophic extension.

2. Guideline-based (not generic) rehabilitation

a. Existing CR literature in aortic-dissection survivors documents favourable functional gains with meticulous blood-pressure monitoring and workloads ≤3–5 METs, but highlights major evidence gaps regarding timing, progression and surveillance imaging.

b. We propose a stepped protocol: (a) confirm aortic stability on repeat CTA/TEE; (b) initiate supervised ambulation at <20 bpm above resting HR and systolic BP <140 mmHg; (c) escalate by ≤0.5 MET per session with weekly imaging or sooner if symptoms occur.

Conclusions:

Early TEVAR should be actively reconsidered, even in borderline surgical candidates, to forestall haemodynamic-triggered propagation. When CR is indicated, programmes must be tailored to TBAD-specific haemodynamic thresholds, with imaging-guided checkpoints. Bridging the current evidence gaps will require prospective trials that integrate vascular, cardiac-rehab, and imaging expertise.

TBA