Background. The extent of proximal and distal aortic resection that should be performed for acute type A aortic dissections remains controversial. Methods. From 1984 to 1999, 119 patients underwent repair of an acute type A dissection. Distal resection was to the ascending aorta in 78 (66%) and hemiarch in 41 (34%) patients. Proximally, the aortic valve was preserved in 69 (58%) patients, 40 (34%) underwent composite valve grafting, and 10 (8%) underwent separate graft and valve replacement. Results. Operative mortality was higher for separate graft and valve (50% ± 16%) than for valve preservation (16% ± 5%) or composite grafts (20% ± 7%) (p < 0.05). Hemiarch replacement did not increase operative risk compared to distal reconstruction to the ascending aorta (17% ± 6% versus 22% ± 5%, p > 0.71). At 10 years, freedom from reoperation was 81% ± 7% and long-term survival was 60% ± 8%, but neither was related to the proximal or distal surgical technique (p > 0.15). Risk factors for late reoperation included a nonresected primary tear and Marfan syndrome (p < 0.05). Conclusions. An aggressive surgical approach, including a full root or hemiarch replacement, is not associated with increased operative risk and should be considered when type A dissections extensively involve the valve, sinuses, or arch.