Interval or permanent nonoperative management of acute XXXX .

@entity1 @entity63 @entity2294 @entity337 @entity1129 @entity1580
HYPOTHESIS: Selected @entity1 with acute @entity1129 (ascending) aortic dissection who are treated with delayed operation or nonoperative therapy may have better early and short-term outcomes than was previously expected. DESIGN AND SETTING: Retrospective cohort at a university hospital. SUBJECTS: Data on 75 @entity1 with acute or chronic @entity1580 treated at one institution from January 1, 1985, to November 30, 1997, were analyzed. Of these 75 @entity1 , 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 @entity1 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. MAIN OUTCOME MEASURES: Vascular complications, hospital mortality, and early survival. RESULTS: 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 @entity1 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 @entity1 , 15 (44%) presented with moderate or severe @entity337 , 5 (14%) had evidence of @entity2294 , 6 (21%) had evidence of concomitant coronary @entity63 on electrocardiogram, and 8 (24%) had extension of the dissection into the descending aorta. Four @entity1 (11.8%) died while in the hospital. Of the 34 @entity1 , 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 @entity1 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 @entity1 undergoing delayed surgery or medical treatment only and the group of 41 @entity1 undergoing early operation (P = .42). CONCLUSIONS: Immediate surgical therapy is still recommended for acceptable operative candidates with acute @entity1580 who seek immediate treatment. However, this study permits the following 2 conclusions: (1) @entity1 with @entity1580 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 @entity1 who are not considered operative candidates and who survive the initial @entity1580 without complication may be treated with aggressive medical therapy and achieve acceptable early and short-term outcomes, which is better than previously expected.
