Type A Aortic Dissection

Type A aortic dissection (TAAD) constitutes a surgical emergency. Without intervention, early mortality is high, driven by aortic rupture, cardiac tamponade, acute aortic regurgitation, coronary malperfusion, or stroke. [@hagan2000] [@trimarchi2005] Current guidelines emphasize that management by a multidisciplinary aortic team in high-volume centers is associated with improved survival [@aha2022-b] [@aha2022-f] [@aha2023-writing] [@esvs2025].

**Clinical Presentation**

The classic presentation is sudden, severe "tearing" or "ripping" chest pain radiating to the back. However, presentations vary widely. Clinicians should maintain a high index of suspicion in patients with known genetic predispositions (e.g., Marfan syndrome) or a strong family history of aortic disease [@aha2022-b]:[@aha2022-b] [@aha2022-f]:

* **Anterior chest pain:** Suggests ascending aortic involvement
* **Interscapular pain:** Suggests arch or descending extension
* **Syncope:** May indicate tamponade, stroke, or severe hypotension
* **Neurologic deficits:** Stroke (arch vessel involvement), paraplegia (spinal cord ischemia)
* **Limb ischemia:** Pulse deficits from iliac extension or obstruction
* **Abdominal pain:** Visceral malperfusion

Physical examination may reveal blood pressure (BP) differential between arms (greater than 20 mmHg), new aortic regurgitation murmur, or signs of tamponade (hypotension, elevated jugular venous pressure (JVP), muffled heart sounds).

**Diagnosis**

Computed tomography angiography (CTA) is the diagnostic modality of choice—rapid, widely available, and highly sensitive and specific. Findings include intimal flap, true and false lumens, and extent of dissection. Transesophageal echocardiography (TEE) is an important adjunct, particularly for assessing aortic valve involvement, pericardial effusion, and coronary ostia. [@hiratzka2010] [@isselbacher2022] [@aha2022-f] [@aha2023-d]

**Surgical Management**

Emergent open surgical repair is the standard of care for TAAD. Initial medical management focuses on aggressive heart rate and blood pressure control, typically targeting a systolic blood pressure (SBP) < 120 mmHg to reduce aortic wall stress [@aha2022-b] [@aha2023-writing].[@aha2022-f] [@aha2023-writing] [@aha2023-d].

* **Ascending aorta replacement:** With or without aortic root replacement. In suitable patients, valve-sparing root replacement (VSRR) is preferred over a composite graft (Bentall procedure) to avoid long-term anticoagulation [@aha2022-b] [@aha2022-f] [@esvs2025].
* **Hemiarch repair:** Replacement of the lesser curvature of the arch under hypothermic circulatory arrest.
* **Total arch replacement:** Indicated when the arch is aneurysmal, contains a primary entry tear, or is extensively dissected. This may involve the "frozen elephant trunk" (FET) technique to facilitate future distal repair [@aha2022-b] [@aha2022-f] [@esvs2025].

Adjunctive measures include antegrade cerebral perfusion during circulatory arrest to reduce neurologic injury. Contemporary registry data and guideline syntheses support operative repair as the default strategy in eligible patients, with outcomes influenced by malperfusion, age, and center experience. [@trimarchi2005] [@isselbacher2022] [@aha2022-f] [@aha2023-writing] [@aha2023-d]

**Hybrid and Endovascular Approaches**

Selected TAAD cases may be candidates for hybrid approaches combining open ascending repair with endovascular arch/descending treatment. Purely endovascular Type A repair remains investigational and is limited to highly selected patients who are prohibitive surgical risks. [@isselbacher2022] [@aha2022-b] [@aha2022-f]