A Comprehensive Review of Acute Type A Aortic Dissection: Epidemiology, Classification, Management Strategies, Mortality Risk Assessment, and Ethical Considerations for Patients who Refuse Blood Transfusions

Acute type A aortic dissection (ATAAD) is a life-threatening cardiovascular surgical emergency with a mortality of 20-25%. This review offers an overview of current research on the morphology, taxonomy, epidemiology, and anesthetic, perfusion, and surgical strategies involved in ATAAD. Moreover, this review examines methods for predicting mortality risk and explores clinician-patient interactions, particularly those involving patients who refuse blood transfusions. The literature search included PubMed, Google Scholar, Web of Science, and ScienceDirect databases, as well as any relevant books. This review references 144 sources: 129 peer-reviewed articles and 15 book chapters or books. Modern classification systems utilize aortic zones based on the location of intimal tears and the extent of dissection; recent updates have included coronary artery dissection as an additional mapping criterion. Socioeconomic factors are linked to higher ATAAD incidence and poorer long-term survival post-surgery. The duration of global myocardial ischemia correlates with mortality and is a key element in the surgical strategy. Compared to deep hypothermic circulatory arrest (HCA), moderate HCA with cerebral perfusion provides benefits such as reduced bleeding and improved survival. Standard prediction models may not accurately assess risks in patients with life-threatening anemia who refuse blood transfusion. Therefore, incorporating Auckland and Hamilton anemia mortality risk scores alongside conventional tools can improve prognostic accuracy and support personalized management. An interpretive-deliberative model balances patient preferences with surgical outcomes, especially in bloodless surgery. Advances in surgical and endovascular management, as well as postoperative strategies for residual aortic disease, have also been explored. Significant progress has been made in assessing in-hospital mortality, improving doctor-patient communication, refining anesthetic and perfusion techniques, and enhancing surgical management of ATAAD. However, further research is needed to validate these approaches.