We read with great interest the article by Tanaka et al. reporting their institutional experience with mechanical circulatory support (MCS) in patients undergoing surgical repair of acute type A aortic dissection (ATAAD) [1]. This study addresses a long-standing and controversial question: whether the intra-aortic balloon pump (IABP), traditionally considered contraindicated in aortic dissection, can be used safely after ATAAD repair – and whether such feasibility translates into meaningful clinical benefit. The authors should be commended for addressing this challenging and underexplored field.

Current major guidelines for aortic disease (ACC/AHA 2022) do not provide specific recommendations regarding IABP use after ATAAD repair [2].

In clinical practice, however, IABP is traditionally considered contraindicated in aortic dissection because of the theoretical risk of propagation, rupture, or worsening aortic regurgitation, as reflected in surgical society resources (e.g., AATS TSRA Primer) and traditional device teaching materials [3]. Tanaka et al. describe 20 patients supported with IABP after acute type A aortic dissection repair, with no device-related aortic complications.

However, this study has important limitations: it is retrospective, single-center, spans more than 20 years, and includes a relatively small cohort (n = 31 requiring support, 20 IABP, 11 ECMO) [1]. Case selection, changes in surgical practice, and unmeasured confounders likely influenced outcomes. The absence of immediate IABP-related complications is reassuring, but late aortic events may have been underestimated, as follow-up imaging was available in only a minority of patients (8/20). Furthermore, case reports exist describing aortic dissection as a direct complication of IABP, including a recent example of acute descending thoracic dissection shortly after device insertion, requiring endovascular repair [4]. At the same time, these observations must be interpreted with caution and within the methodological constraints of the study. This challenges established dogma and suggests that, under selected conditions, IABP may be safer than previously assumed.