Surgical Management of Acute Type A Aortic Dissection

Acute type A aortic dissection (ATAAD) is a life-threatening cardiovascular emergency characterized by disruption of the ascending aortic intima with subsequent propagation of a false lumen. Population-based studies report an annual incidence of approximately 3 cases per 100,000 patient-years. Despite advances in diagnosis and surgical management, 30-day operative mortality remains approximately 10-20%, with higher rates in the presence of malperfusion syndrome, cardiac tamponade, or aortic rupture. This narrative review summarizes the current understanding of ATAAD pathophysiology, classification systems, diagnostic modalities, and evolving management strategies, with particular emphasis on contemporary surgical techniques and organ protection strategies employed during repair. Hypertension remains the most significant modifiable risk factor for ATAAD, whereas hereditary thoracic aortic disease (HTAD) predisposes younger patients to dissection. The Penn classification stratifies mortality risk according to the pattern of malperfusion; coronary and mesenteric malperfusion are associated with the highest mortality. Surgical management has evolved from traditional hemiarch replacement to more extensive arch replacement, with or without frozen elephant trunk (FET) techniques, and emerging data demonstrate improved long-term durability. Moderate hypothermic circulatory arrest (MHCA) with antegrade cerebral perfusion (ACP) has emerged as the preferred neuroprotective strategy, offering outcomes comparable to those achieved with deep hypothermic circulatory arrest (DHCA) alone. Treatment at high-volume comprehensive aortic centers is associated with improved survival. Management of ATAAD continues to evolve through ongoing refinements in surgical techniques, organ-protection strategies, and perioperative care. While prompt surgical intervention remains the cornerstone of treatment, individualized management that incorporates patient-specific anatomy, malperfusion patterns, and institutional expertise is essential. Long-term surveillance and follow-up at specialized aortic centers are critical for detecting and managing late complications, and genetic evaluation is recommended to identify HTAD in appropriate patients.