Scholl F G, Coady M A, Davies R, Rizzo J A, Hammond G L, Kopf G S, Elefteriades J A
Department of Surgery, Yale University School of Medicine, New Haven, Conn 06510, USA.
Arch Surg. 1999 Apr;134(4):402-5; discussion 405-6. doi: 10.1001/archsurg.134.4.402.
Selected patients with acute type A (ascending) aortic dissection who are treated with delayed operation or nonoperative therapy may have better early and short-term outcomes than was previously expected.
Retrospective cohort at a university hospital.
Data on 75 patients with acute or chronic type A aortic dissection treated at one institution from January 1, 1985, to November 30, 1997, were analyzed. Of these 75 patients, 34 (21 male and 13 female, with a mean age of 65.5 years) did not undergo initial operative treatment, and 15 (10 male and 5 female, with a mean age of 72.6 years) never underwent surgery. For the 19 patients who underwent delayed surgery, the mean period between aortic dissection and intervention was 11.4+/-4.83 days. The follow-up period ranged from 0.27 to 149 months, with a mean of 20.2 months.
Vascular complications, hospital mortality, and early survival.
Reasons for interval delay in surgical treatment included initial misdiagnosis or delay in diagnosis (13 [68%] of 19), need to address significant comorbidity (4 [21%] of 19), and initial refusal of operative intervention (2 [11%] of 19). For the 15 patients treated entirely by medical therapy, reasons for electing nonoperative management included extensive comorbidity (5 [33%] of 15), refusal of surgical intervention (6 [40%] of 15), and misdiagnosis or long delay in diagnosis (4 [27%] of 15). Of the 34 patients, 15 (44%) presented with moderate or severe aortic insufficiency, 5 (14%) had evidence of pericardial effusion, 6 (21%) had evidence of concomitant coronary ischemia on electrocardiogram, and 8 (24%) had extension of the dissection into the descending aorta. Four patients (11.8%) died while in the hospital. Of the 34 patients, 30 (88%) who underwent either delayed or no surgery received aggressive medical treatment (beta-adrenergic blocking agents and afterload-reducing agents) and were discharged from the hospital. All patients who were operative candidates in the interval treatment group survived to reach definitive operation. There was no statistically significant difference in short-term survival between the group of patients undergoing delayed surgery or medical treatment only and the group of 41 patients undergoing early operation (P = .42).
Immediate surgical therapy is still recommended for acceptable operative candidates with acute type A aortic dissection who seek immediate treatment. However, this study permits the following 2 conclusions: (1) patients with type A aortic dissection who are referred or whose conditions are diagnosed several days after presentation have survived the early dangerous period and can safely undergo surgery semielectively (rather than emergently); and (2) selected patients who are not considered operative candidates and who survive the initial type A aortic dissection without complication may be treated with aggressive medical therapy and achieve acceptable early and short-term outcomes, which is better than previously expected.
部分接受延迟手术或非手术治疗的急性A型（升主动脉）主动脉夹层患者，其早期和短期预后可能优于先前预期。
大学医院的回顾性队列研究。
分析了1985年1月1日至1997年11月30日期间在同一机构接受治疗的75例急性或慢性A型主动脉夹层患者的数据。这75例患者中，34例（21例男性和13例女性，平均年龄65.5岁）未接受初始手术治疗，15例（10例男性和5例女性，平均年龄72.6岁）从未接受手术。对于19例接受延迟手术的患者，主动脉夹层与干预之间的平均时间为11.4±4.83天。随访期为0.27至149个月，平均为20.2个月。
血管并发症、医院死亡率和早期生存率。
手术治疗延迟的原因包括初始误诊或诊断延迟（19例中的13例[68%]）、需要处理严重合并症（19例中的4例[21%]）以及初始拒绝手术干预（19例中的2例[11%]）。对于15例完全接受药物治疗的患者，选择非手术治疗的原因包括广泛合并症（15例中的5例[33%]）、拒绝手术干预（15例中的6例[40%]）以及误诊或诊断长期延迟（15例中的4例[27%]）。34例患者中，15例（44%）出现中度或重度主动脉瓣关闭不全，5例（14%）有心包积液证据，6例（21%）心电图有合并冠状动脉缺血证据，8例（24%）夹层扩展至降主动脉。4例患者（11.8%）在住院期间死亡。34例患者中，30例（88%）接受了延迟手术或未手术，接受了积极的药物治疗（β-肾上腺素能阻滞剂和减轻后负荷药物）并出院。间隔治疗组中所有有手术指征的患者均存活至接受确定性手术。接受延迟手术或仅接受药物治疗的患者组与41例接受早期手术的患者组在短期生存率上无统计学显著差异（P = 0.42）。
对于寻求立即治疗的可接受手术的急性A型主动脉夹层患者，仍建议立即进行手术治疗。然而，本研究得出以下两个结论：（1）就诊时被转诊或在发病数天后被诊断出病情的A型主动脉夹层患者已度过早期危险期，可安全地进行半选择性手术（而非急诊手术）；（2）部分不被视为手术候选者但在初始A型主动脉夹层中存活且无并发症的患者，可接受积极的药物治疗并取得可接受的早期和短期预后，这比先前预期的要好。
