Objectives <p>Acute type A aortic dissection (ATAAD) patients with isolated left vertebral artery (ILVA) are at greater risk of brain damage during perioperative period. This study aims to evaluate the prognosis of ATAAD patients with ILVA.</p> Methods <p>This retrospective cohort study enrolled ATAAD patients and assigned them to the ILVA group or control group based on the presence of ILVA. A 1:2 propensity score matching (PSM) was employed using gender, age and surgical method. The primary outcome was defined as the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) at 18-month follow-up, which included all-cause death, myocardial infarction and stroke.</p> Results <p>Following PSM, 117 patients were enrolled, including 39 patients in the ILVA group. The ILVA group had higher incidences of MACCE [19 (48.7%) vs. 11 (14.1%), <i>P</i> &lt; 0.001], all-cause death [17 (43.6%) vs. 9 (11.5%), <i>P</i> &lt; 0.001] and stroke [5 (12.8%) vs. 2 (2.6%), <i>P</i> = 0.018] compared to the control group. Multivariate cox regression indicated that ILVA [HR = 2.60, 95%CI: 1.17–5.80, <i>P</i> = 0.019], renal insufficiency [HR = 1.93, 95%CI: 1.10–3.39, <i>P</i> = 0.023] and cardiopulmonary bypass (CPB) time [HR = 1.01, 95%CI: 1.00-1.01, <i>P</i> = 0.026] were independent risk factors for MACCE at 18-month. There was no significant difference in the modified Rankin scale scores at 18-month. ILVA was not significantly associated with in-hospital mortality.</p> Conclusions <p>The incidence of MACCE at 18-month follow-up was higher in ATAAD patients with ILVA. ILVA, renal insufficiency and CPB time were identified as risk factors for MACCE for ATAAD patients. ILVA might serve as a risk factor for cardiovascular risk, but not for early postoperative mortality. Special attention should be attached to ATAAD patients with ILVA to improve the long-term prognosis.</p>