Background Acute type A aortic dissection (ATAAD) is a surgical emergency with an operative mortality of up to 30%, a rate that has not changed meaningfully in more than 2 decades. A growing body of research has highlighted several comorbidities and presenting factors in which delay or permanent deferral of surgery may be considered; however, modern comprehensive summative reviews are lacking. The urgency and timing of this review are underscored by significant challenges in resource use posed by the coronavirus disease 2019 (COVID-19) pandemic. This review provides an update on the current understanding of risk assessment, surgical candidacy, and operative timing in patients with ATAAD. Methods A literature search was conducted through PubMed and Embase databases to identify relevant studies relating to risk assessment in ATAAD. Articles were selected by group consensus on the basis of quality and relevance. Results Several patient factors have been identified that increase risk in ATAAD repair. In particular, frailty, advanced age, previous cardiac surgery, and use of novel anticoagulant medications have been studied. The understanding of malperfusion syndromes has also expanded significantly, including recommendations for surgical delay. Finally, approaches to triage have been significantly influenced by resource limitations related to the ongoing COVID-19 pandemic. Although medical management remains a reasonable option in carefully selected patients at prohibitive risk for open surgery, endovascular therapies for treatment of ATAAD are rapidly evolving. Conclusions Early surgical repair remains the preferred treatment for most patients with ATAAD. However, improvements in risk stratification should guide appropriate delay or permanent deferral of surgery in select individuals.
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