Identifying the entry site is very important. It identifies those at risk for rupture and in need of emergent surgery: 70% of the primary tears in ascending aortic and arch dissection are located in the ascending aorta, of which 86% are within the first 4 cm of the ascending aorta and another 10% within the next 4 cm. Most of the external rupture occurs at the site of the initial tear and hence recognition of the site of the intimal tear has an impact on the surgical approach. Intrapericardial rupture occurred in 70% of cases when the dissection began in the ascending aorta, 35% in cases where it began in the arch and 12% in those where the dissection began from the descending thoracic aorta17. Both pulsed and color flow Doppler have characteristic patterns at the entry site that allow correct recognition of the true and false lumens. The site of the entry tear in the distal ascending and proximal arch has surgical implications. Repairing the intra pericardial ascending aorta without addressing the primary entry site in the distal proximal or arch of the aorta will only prevent potential sudden death from rupture into the pericardial sac but does not eliminate the complications resulting from continued blood flow into the false lumen.
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