Acute aortic dissection (AAD) has always been a challenging clinical emergency, with an estimated annual global prevalence of 1.4 to 20 million. The majority of the disruptions are in the ascending aorta (65%), the arch (10%), the descending aorta (20%), and the abdominal aorta (5%), and often multiple disruptions can occur. Possible mechanisms of hemodynamic obstruction include: separation of the intima and mesentery from the vessel wall attachment as a sheet between the true and false lumen, which floats and oscillates against the flow; static obstruction due to thrombus formation in the intercalated overlying or vascular population; and compression of the true lumen by an enlarged false lumen. Both the classical taxonomy Debakey and Standford typing take whether the entrapment involves the ascending aorta as a criterion for diagnosis and treatment, while Sun Lizhong et al. attempted a refined typing of aortic entrapment based on Stanford typing, which helps to develop specific treatment plans for the characteristics of Chinese cases. The innovation of extracorporeal circulation and cerebral perfusion techniques in the past 30 years, especially the development of minimally invasive interventional techniques in recent years, has significantly improved the treatment outcome of AAD, and thus new diagnostic and therapeutic perspectives have begun to challenge the traditional concepts. AAD has an hourly mortality rate of 1% in the first 48 hours, and about 6% of patients are pain-free. The diseases that need to be differentiated are acute coronary syndrome, pericarditis, pulmonary embolism or cholecystitis. Transthoracic or esophageal ultrasound, enhanced CT, and MRI are commonly used to confirm the diagnosis of entrapment, and their diagnostic compliance rates are similar, but the ability to detect associated complications varies from each other. (1) X-ray chest radiograph: non-specific for the proposed diagnosis of entrapment; (2) ECG: severe chest pain and normal ECG suggest possible distal entrapment; (3) ultrasound: transthoracic ultrasound can detect combined or involved cardiac disease and also identify pulmonary embolism, etc., while transesophageal ultrasound shows vague aortic arch, but has a confirmatory value for distal entrapment and entrapment with iliac artery or superior mesenteric artery involvement Chuan; (4) cT vascular (4) computertomograph angiography (CTA): currently the preferred diagnostic method, ultrathin CTA can scan the whole aorta, including the iliac and femoral arteries, and can identify true and false lumens and suggest the involvement of branch vessels, and 3D reconstruction technology can further enhance the diagnostic accuracy; (5) intravascular ultrasound: used to help identify the presence of intramural hematoma. It can accurately describe the physiological changes of perfusion disturbance in branch vessels; (6) magnetic resonance angiography: used in cases of allergy to contrast agents or renal insufficiency; (7) aortography: highly invasive, high-risk, and limited in application; (8) molecular diagnosis: currently in its infancy, genetic markers and specific gene defects are being studied, and these biological markers can help warn of the risk of aortic disease; (9) biochemical indicators: such as genetic markers and specific gene defects, etc. Risk; ⑨ biochemical indicators: such as elevated plasma D a dimer has a certain diagnostic value. The primary management of AAD remains the reduction of pain and control of blood pressure and heart rate. In patients with normal or low blood pressure, prediction of blood volume, pericardial effusion and cardiac function status should be performed before medication. Patients are generally controlled to have a systolic blood pressure below 120 mmHg, but nearly 2/3 of patients with Stanford type B entrapment have hypertension that is difficult to control or ineffective to medication¨. Patients with severe hemodynamic instability often require mechanical assist ventilation and immediate bedside ultrasound or rapid CT imaging. An ultrasound diagnosis of cardiac tamponade may lead to immediate open-heart surgery, when percutaneous pericardiocentesis alone can accelerate bleeding and shock. In survivors of AAD, it is critical to maintain blood pressure at a low level over time. The in-hospital mortality rate for medical treatment is approximately 10%, rising to 1/3 in the case of acute complications and emergency surgery. Surgical treatment: 1. Type A clamping: For proximal type A AAD, the surgical purpose is mainly to prevent the occurrence of clamping rupture and pericardial tamponade. Sudden aortic valve insufficiency and acute coronary artery obstruction also require urgent surgical intervention to remove the torn portion of the intima of the ascending aorta and replace it with an artificial vessel, provided that the aortic valve remains intact or can be shaped. When the coarctation extends into the aortic arch or descending aorta and complete excision of the detached intimal piece is difficult, partial or total aortic arch replacement is required. If the valve leaflets are intact the David or Yacoub aortic valve suspension technique may be used¨ ” . Cases should be carefully selected for emergency management and performed by experienced and technically sophisticated surgical specialists. Intercalation without aortic root dilatation requires first clarification of the aortic valve leaflet junction, followed by the relationship of the coronary opening to the intercalation. If the entrapment threatens the left and right coronary artery openings but has not yet involved the vessel, the openings should generally be preserved; if the openings are completely stripped, a new coronary artery graft is required. In cases of coronary artery opening tears, coronary artery bypass grafting or Cabrol surgery can be performed in the saphenous vein. If the aortic valve needs to be replaced and the coronary artery opening is intact, the Wheat procedure can be performed. If the operator’s experience is limited or limited, the Bentall procedure is safer. In particular, the Bentall procedure is still favored by the majority of operators for acute type A coarctation with proximal aortic dilatation caused by Marfan syndrome, etc. The Stanford Center 15] reported that 20% to 30% of patients have unrecognized intimal fissures in the aortic arch or descending aorta, resulting in a possible need for reoperation of the distal aorta. 2. aortic arch entrapment: The current discussion focuses on the optimal timing of arch replacement. 30% of patients with AAD may have an arch tear, and if the tear ruptures across the aortic arch, it is necessary to decide in advance on the length of the prosthetic vessel to replace the arch beyond the plane of the tear. In AAD with a wide distribution of tears across the transverse aortic arch or with a previous arch aneurysm, partial or complete cephalobrachial artery coupling to an artificial vessel is required for secondary or total arch replacement. The use of an artificial four-branch vessel allows for resection of the diseased cephalobrachial vessels and also reduces the likelihood of secondary surgery by reducing residual postoperative arch re-expansion. In Stanford type A coarctation, when the primary endothelial rupture is located in the arch or in the descending aorta and the arch is severely involved, the aortic arch replacement combined with the braced elephant trunk technique can be used; the reverse elephant trunk technique refers to the inversion of the artificial vessel into a double layer, with the outer layer used for thoracoabdominal aortic replacement and the inner layer used for aortic arch replacement during stage II surgery. If the lesion is more extensive, reverse and cis-bi-directional pictorial surgery can be performed on the proximal and distal sides of the thoracic aorta respectively. Currently, the most popular technique is to replace open surgery in stage II with an artificial vascular overlay stent implantation through a transfemoral arterial puncture. DHCA does not reduce the early complications of AAD and does not improve postoperative survival. postoperative survival. The cascade SCP, with its more physiological perfusion, significantly reduces neurological complications and prolongs the surgical safety time frame, and can significantly improve the postoperative survival rate of patients with type A AAD, but its application is limited in patients with infection, traumatic, entrapment involving the cephalobrachial vessels or with carotid or cephalobrachial vascular lesions, but the above patients can be cannulated by the axillary artery because the entrapment rarely invades the axillary artery. Retrograde cerebral perfusion is quite controversial in clinical application because it does not conform to the physiological pattern, difficult to grasp the perfusion pressure and easy to destroy the blood-brain barrier; however, it can maintain cerebral hypothermia and exclude the air thrombus in cerebral circulation, so it still has the advantage of clinical application. 3, type B entrapment: conservative treatment for type B entrapment was often taken in the past, this is because it has not been confirmed that surgical repair is superior to medical or mediator treatment for stable patients, but emergency surgery should still be considered for type B entrapment that has formed an aneurysm. With recent advances in surgical techniques and marked improvements in treatment outcomes, surgical-based treatment options are again becoming attractive with the aim of preventing or mitigating life-threatening complications. The current belief is that the best surgical management for complications of type B entrapment is aortic reconstruction, with the principle of management being the replacement of the shortest possible aortic segment provided that the lesioned area is removed as much as possible, and that the proximal and distal anastomoses should be at or near normal aortic diameter. Initial surgical treatment to correct visceral, renal, and lower extremity ischemia includes aortic windowing, collateral vessel diversion, and temporary anatomic shunts, which can be reasonably selected based on case characteristics. The greatest drawback of open or diverted aortic surgery is that it does not detect the most important pathologic change, the aortic breach, and it also increases aortic injury, making early diagnosis of visceral ischemia difficult. Revascularization of the celiac, superior and inferior mesenteric, renal and iliac arteries is important to restore blood supply to vital organs and improve prognosis, and the use of four-branch artificial vessels and the optimal design of anastomotic techniques simplify surgical operations. The management of the intercostal arteries is a highly promising area of innovation, and traditional philosophy supports the reconstruction of as many intercostal vessels as possible to reduce the risk of lower limb paralysis. Sun Lizhong et al. further simplified the anastomosis technique by forming the thoracic aorta at the opening of the 6th to 12th pair of intercostal arteries into a single tube before anastomosing it with a branch of the artificial vessel. However, current imaging techniques do not confirm that reconstruction of the intercostal arteries prevents the occurrence of paraplegia, and some data suggest that such reconstruction is often unnecessary and that newer methods of spinal cord perfusion may be the most effective. Fourth, interventional treatment increases the risk of surgical procedures due to advanced age, connective tissue disorders, enlarged aortic lesions, and visceral or cerebral ischemia. Interventional treatments include openings, visceral vascular stents and endovascular stent implants, which improve the physiological status of the patient and avoid surgical reconstruction. Even proximal entrapment with stenting or windowing before the time is ripe for surgery can ensure blood supply to important branch vessels. Some centers advocate intervention only when patients present with definite complications, but others strongly believe that it is indicated early in patients with a variety of uncomplicated clips to avoid their late complications. The disagreement over interventional therapy stems mainly from a lack of awareness of its durability and risk-benefit ratio of treatment outcomes. 1. Indications for windowing and stent replacement: Indicated for hemodynamic abnormalities caused by perfusion disorder syndrome, intimal collapse, collateral vessel obstruction, or progressive enlargement of the pseudolumen. The therapeutic objectives include closure of the entrapment breach, induction of aortic remodeling, false lumen thrombosis, and restoration of collateral blood flow. The opening greatly increases the blood flow within the false lumen, thus increasing the risk of aortic dissection, and the spillover of thrombus within the false lumen can cause peripheral embolism. The most effective way to avoid pseudolumen enlargement and aneurysmal dilatation is to stent the vessel to close the proximal breach and decompress and reduce the pseudolumen through thrombosis and aortic remodeling. A perforated stent establishes the blood supply to the aortic branches, and stent implantation makes sense when there is a significant pressure gradient between the branch artery and the aortic lumen supplying blood to it. 2. Therapeutic effect: precise placement can stabilize the hemodynamic state by effectively fixing the free wall of the stent. It is important to assess the true luminal cross-section of the aorta and the intra-luminal pressure after blood flow is restored. Paraplegia has become quite rare, mainly in cases with multiple stented vessels. Short-term follow-up is satisfactory, with imaging showing closure of the breach, progressive reduction in aortic diameter, and a 1-year survival rate of >90% . Patients may experience some inflammatory response after stenting, which may resolve spontaneously or with non-steroidal medication. Neglect of the original breach often leads to initial treatment failure, and late residual leaks also occur. Opening and stenting can sometimes lead to adverse hemodynamic changes in the true or false lumen, so that reintervention can be performed. Deaths associated with the intervention itself are uncommon, and the rate of postoperative morbidity and mortality is largely determined by the severity and duration of organ ischemia prior to treatment. V. Long-term follow-up and treatment An estimated 1/3 of patients with AAD who survive medical treatment will develop future coarctation dilatation, aortic aneurysm formation, or aortic dissection, and dilatation, coarctation, or dissection of the aorta within a small distance of the surgical suture margin and from it is common. Hypertension, advanced age, abnormal aortic morphology, and potential pseudoluminality are all high-risk factors for developing AAD, as is the entire spectrum of the equine syndrome. the use of B-blockers is a milestone in medical therapy, and treatment guidelines recommend gradually increasing the intravenous dose, maintaining blood pressure at <135/80rnmHg in general patients and <130/80mmHg in patients with equine syndrome. Continuous imaging observation of the aorta after surgical procedures or stent vascularization allows for timely detection of changes in disease. Follow-up examinations are recommended to receive radiography at intervals of 1, 3, 6, 9 and 12 months and once a year thereafter. Imaging cannot be simply limited to the initial lesion area, as entrapment and aneurysm formation can occur anywhere in the aorta. Patients with Marfon syndrome with an enlarged ascending aorta of 5 to 5.5 cm in diameter are surgical indications, aorta >5.5 to 6.0 cm can be identified for surgery, and all types of patients with distal aortic dilatation >6.0 cm should also undergo surgery. The incidence and consultation rate of aortic disease in the cardiovascular morbidity group is increasing, and there is an urgent need for early diagnosis using early biomarkers and functional imaging of the aortic wall. Treatment with improved extracorporeal circulation and surgical techniques has led to significant improvements in safety, and current treatment options that combine surgical and interventional techniques, known as hybridization, are being adopted, further expanding the scope of treatment for AAD, improving outcomes, and increasing survival rates in the near to mid-term. Cardiologists should continuously improve the diagnosis and classification of AAD, form specific treatment assignment networks and localization systems, optimize uniform follow-up procedures, and it is necessary to establish an integrated multidisciplinary team to prospectively register and validate retrospective observations of aortic disease in order to continuously improve treatment strategies.