Aortic dissection is characterized by the separation of the layers of the media by a column of circulating blood with variable proximal and distal extension throughout the entire length of the aorta. The extravasated blood may remain within the false lumen with eventual thrombosis or may rupture through the aortic wall leading to fatal haemorrhage into the pericardium or left pleura.Standford classification system identifies two types of dissection, type A dissections involve the ascending aorta while type B dissections involve the descending aorta distal to the left subclavian artery. This classification is important as it reflects treatment options.Acute aortic dissections remains the most catastrophic illness involving the aorta and has an incidence of 5-10 cases per 100,000 per year and accounts for about 1.5 deaths per 100,000 males and 0.6 per 100,000 females per yearDissections occurs typically in the middle aged or older men, and is associated with hypertension in up to 90% of cases, other risk factors include connective tissue disorders, congenital heart diseases, pregnancy and trauma following catheterisation.The diagnosis of acute aortic dissection is straightforward when the patient has classic symptoms of sudden, severe tearing chest pain with subsequent caudal migration along the course of the aorta. The patient may also have evidence of neurological deficit or evidence of myocardial affection. Aortic dissection should be included in the differential diagnosis of myocardial infarction, cerebrovascular accidents, and spinal cord syndromes of sudden onset. The use of thrombolytic therapy in patients with acute aortic dissection who have been incorrectly diagnosed as having an acute myocardial infarction can have fatal consequences.Among the optional imaging studies to reach the proper diagnosis for dissection, aortography has conventionally been considered, but recently with the evolution of high technology transeosophageal echocardiography, computed tomography and magnetic resonance imaging have a high sensitivity and specificity for diagnosis of aortic dissection.Once the diagnosis has been made, treatment needs to be instituted rapidly. Untreated patients with acute aortic dissection have an early mortality approaching 1-3% per hour. It is recommended to treat type A dissections with surgery and type B dissections with medical therapy, however, there is growing amount of literature that suggests operative treatment of acute type B dissections results in better outcome in some cases. Classic indications for surgery in acute type B dissections include failure of medical therapy to control blood pressure and pain, diameter greater than 5 cm, renal failure, paresis, paraplegia, leg ischaemia, bowel ischaemia, bloody pleural effusion, frank rupture and respiratory compromise. In both types of acute aortic dissection, the emergency department management includes control of pain and blood pressure.Blood pressure is controlled by intravenous infusion of nitroprusside and a beta blocker. The goal is to lower the blood pressure to the lowest level that is consistent with adequate organ perfusion, usually a mean arterial pressure of 60-75mmHg. After the patient is stabilized and diagnostic evaluation is carried out, definitive surgical treatment is performed aiming at identification and obliteration of the intimal tear, prevention of expansion and rupture of the aorta by replacement with an interposition graft.Various endovascular techniques have become viable therapeutic alternatives of patients with acute aortic dissections. This technique is less invasive and is associated with acceptable mortality and morbidity rates. Patients who are particularly likely to benefit include the very elderly population; those with markedly compromised cardiac, pulmonary, or renal status; and individuals who have previously undergone complex operations on the thoracic aorta.Cardiac anaesthesia continues to advance in understanding the causes of complications that occur during aortic surgery and in preventing their occurrence. Monitoring of vital organs like the brain, spinal cord, kidneys and the heart improve the outcome.Brain protection is essential in aortic surgery and can be achieved by profound hypothermic circulatory arrest and retrograde cerebral perfusion. Spinal cord protection can be achieved by shunts and bypass techniques and additional measures include hypothermia and spinal fluid drainage and implantation of patients intercostals arteries between T9 and L1.