<p>Few studies have explored the impact of different primary entry tear sites in acute type A aortic dissection. We aimed to evaluate the effect of the primary entry tear location on presentation, treatment, and outcome in this condition. We retrospectively reviewed acute type A aortic dissection repair surgical records at our institution (2004 and 2020) (<i>n</i> = 213). The patients were classified into the ascending aorta entry (As-E), aortic arch entry (Ar-E), and descending thoracic aorta or downstream entry (Dd-E) groups. The As-E group was the oldest (<i>P</i> &lt; 0.01) and included the fewest males (<i>P</i> &lt; 0.01). Pre-operative neurological complication rates were highest in As-E, 16%; Ar-E, 5%; and Dd-E, 0% (<i>P</i> = 0.03). Malperfusion syndrome rates were as follows: As-E, 10%; Ar-E, 2%; and Dd-E, 0% (<i>P</i> = 0.05). As-E was associated with the highest in-hospital mortality (As-E, 13%; Ar-E, 8%; Dd-E, 0%; <i>P</i> = 0.27). In-hospital mortality risk factors included pre-operative neurological complications, malperfusion syndrome, and concomitant procedures. Subanalysis revealed that ascending aortic entry was an independent risk factor for pre-operative acute neurological complications. The primary entry site may indirectly affect outcomes, by mediating the risks of pre-operative complications, which are linked to mortality.</p>