IMPROVE-AD: Randomized trial for uncomplicated Type B Aortic Dissection

In the complex world of vascular surgery, where “high risk” is basically our love language, one topic continues to spark the debate: the uncomplicated type B aortic dissection. “Uncomplicated” may sound reassuring, but don’t be fooled. In reality, “uncomplicated” may just mean not yet complicating your life. These patients represent the calm before the storm, leaving clinicians to weigh whether it’s better to follow a conservative approach or go in early and do something heroic (and preferably endovascular).

Once upon a time, all type B dissections were approached as ticking time bombs — open surgery, big incisions and lots of drama. Outcomes, however, were far from ideal. As evidence emerged that doing less often yielded better results, the field shifted direction. Medical therapy became the dominant approach; enter the era of “let’s control the blood pressure and hope for the best.” Today, medical therapy — mainly antihypertensives and analgesics — remains the cornerstone for managing uncomplicated type B dissections.

Short-term survival left everyone quite satisfied: in-hospital survival was about 90%. Long-term results, however, were less pleasing. Survival drops to around 79% at five years, with approximately one-third of these initially “uncomplicated” patients eventually requiring intervention – procedures that are technically more challenging in the chronic phase with higher procedural risks. Turns out, “uncomplicated” is more complicated than it sounds.

Superficial venous intervention has transformed the treatment of varicose veins, offering patients minimally invasive solutions with excellent short-term outcomes. Yet, despite technical advances, an important question remains unresolved: Should pharmacological thromboprophylaxis be routinely prescribed to prevent postoperative deep vein thrombosis (DVT)?

The THRIVE trial (THRomboprophylaxis In superficial endovenous interVEntion) is the first randomised controlled study designed to address this uncertainty.1 By generating robust clinical evidence, THRIVE has the potential to influence international practice and shape future guideline recommendations.

Varicose veins are common, affecting up to 45% of the UK population and are associated with reduced physical and mental health-related quality of life.2,3 Symptomatic varicose veins are now routinely treated with endovenous thermal ablation, non-thermal ablation or mechanochemical techniques.4 While effective, these procedures carry a recognised risk of venous thromboembolism (VTE).

Knee osteoarthritis is one of the most common musculoskeletal conditions, affecting almost one in five people over the age of 45 in the UK — around 4 million people. For many, it means living with chronic pain, limited mobility, and a gradual decline in quality of life. At its most severe, the only effective option is knee replacement surgery.

But what about those who aren’t yet at that stage? Despite trying physiotherapy, anti-inflammatories, and combinations of painkillers, many patients remain stuck in a treatment gap. Their pain is poorly controlled, yet surgery is not an option.

A new approach — genicular artery embolisation (GAE) — might offer hope. The procedure blocks small blood vessels around the knee that are thought to drive inflammation and pain. Early studies have hinted at benefit, but the evidence so far is mixed: one small trial showed no improvement, while another found a modest reduction in pain. Despite this uncertainty, the technique is already being used internationally.