Contemporary Management of Ascending Aortic and Arch Dissection: Integrating Open, Hybrid, and Endovascular Strategies.

Acute aortic dissection is the most frequent presentation of acute aortic syndromes and remains a rapidly progressive and life-threatening condition requiring immediate diagnosis and treatment. Advances in surgical techniques, hybrid strategies, and endovascular technologies have expanded treatment options, particularly for high-risk and anatomically complex patients. This narrative review summarizes current evidence and guideline-based strategies for the management of aortic dissection, with emphasis on acute type A disease. The review integrates data from registries, contemporary clinical trials, meta-analyses, and recent international guidelines. Open surgical repair remains the standard of care for acute type A aortic dissection, providing reliable entry tear exclusion, restoration of true lumen perfusion, and prevention of rupture. Expanded surgical strategies such as frozen elephant trunk improve distal aortic remodeling and reduce late reinterventions in selected patients. Hybrid and adjunctive technologies, including modular dissection stents and branched stented anastomosis techniques, aim to improve distal perfusion and simplify arch reconstruction. Endovascular repair of the ascending aorta is emerging as a potential alternative for high-risk or inoperable patients, supported by early feasibility data and dedicated device development. Management of aortic dissection is rapidly evolving toward individualized, anatomy-driven strategies that integrate open, hybrid, and endovascular therapies. While open surgery remains the cornerstone for acute type A dissection, emerging endovascular technologies may expand treatment eligibility in selected patients. Future progress will depend on continued device innovation, multidisciplinary aortic team models, and prospective clinical trials to define optimal treatment algorithms.