Thoracic Surgery Directors Association Award. What is the optimal management of late-presenting survivors of acute type A aortic dissection?
BACKGROUND
Although type A aortic dissections represent a surgical emergency, some patients present late after the onset of symptoms. Optimal management of this cohort has not been defined.


METHODS
Data on 195 patients with type A dissections followed up at a single institution between 1985 and 2005 were collected prospectively. Of these, 93 patients (47.2%) presented 48 hours or later after the initial onset of pain (group A), and the remaining 102 patients underwent immediate operative repair (group B). Median follow-up was 41.8 months (range, 0 to 386 months).


RESULTS
Patients in group A were older (68.8 versus 59.3 years, p = 0.0005) and had a higher incidence of coronary artery disease (42.5% versus 14.6%, p < 0.0001), pulmonary disease (26.6% versus 8.4%, p = 0.0023), and congestive heart failure (14.1% versus 1.0%, p = 0.0004). Long-term survival was similar, although group B showed a trend toward improved 30-day mortality (16.5% versus 8.7%, p = 0.1035). Of the 92 patients in group A, 53 (57.6%) eventually underwent operative repair a median of 8.2 days after symptom onset. There was a trend toward improved long-term survival among patients undergoing repair (p = 0.1031).


CONCLUSIONS
Initial medical management with interval operative repair of selected patients referred greater than 2 days following an acute type A dissection is a viable option. Delayed repair after optimization of the clinical condition and detailed evaluation of concomitant diseases results in excellent long-term results.
Davies
Ryan R
RR
Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York, USA.
Coe
Marcus P
MP
Mandapati
Divakar
D
Gallo
Amy
A
Botta
Donald M
DM
Elefteriades
John A
JA
Coady
Michael A
MA
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery* / Q000628:therapy; D001014:Aortic Aneurysm / Q000401:mortality / Q000601:surgery* / Q000628:therapy; D019917:Blood Vessel Prosthesis Implantation; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome