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The Japanese Journal of Thoracic Surgery Volume 79, Issue 1 （January 2026）

胸部外科 79巻1号（2026年1月発行）

Japanese English

特集 Stanford A型急性大動脈解離の外科治療

Stanford A型急性大動脈解離の保存的加療 Conservative Management of Stanford Type A Acute Aortic Dissection 奥木聡志 ¹ , 中山泰介 ¹ , 伊藤雄二郎 ¹ , 林祐次郎 ¹ , 黒田美穂 ¹ , 安元勇人 ¹ , 新妻健 ¹ , 古仲美貢 ¹ , 新妻楠望 ¹ , 樋熊佑香 ¹ , 玉川佳澄 ¹ , 中村喜次 ¹ Satoshi Okugi ¹ , Taisuke Nakayama ¹ , Yujiro Ito ¹ , Yujiro Hayashi ¹ , Miho Kuroda ¹ , Yuto Yasumoto ¹ , Ken Niitsuma ¹ , Miku Konaka ¹ , Kusumi Niitsuma ¹ , Yuka Higuma ¹ , Kasumi Tamagawa ¹ , Yoshitsugu Nakamura ¹ ¹千葉西総合病院心臓血管外科 ¹Department of Cardiovascular Surgery, Chiba-Nishi General Hospital キーワード： Stanford A型急性大動脈解離 , 保存的加療 , 外科手術 Keyword: Stanford type A acute aortic dissection , conservative management , surgery pp.15-21

発行日 2026年1月1日 Published Date 2026/1/1

DOI https://doi.org/10.15106/j_kyobu79_15

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参考文献 Reference

Stanford A型急性大動脈解離（Stanford type A acute aortic dissection：AAAD）の標準治療は緊急手術であり，合併症の有無を問わず外科的介入を原則とする方針が主要ガイドラインで一貫している1，2）．根拠は不良な自然予後で，1990～2000年代のレビューでは24時間死亡率21～30％，48時間死亡率37～50％3）であり，急性大動脈解離国際レジストリ（IRAD）の現代解析でも非手術管理群の死亡率は毎時0.5％（48時間23.7％），手術群の48時間死亡率4.4％である4）．

Background：Emergency surgery remains the standard of treatment for acute Stanford type A aortic dissection （AAAD）. Nevertheless, in real-world practice a minority of patients do not undergo immediate surgery due to clinical constraints. We sought to delineate the outcomes and practical limits of such nonoperative management under strict protocols.

Methods：Of 668 consecutive AAAD patients （Jan 2019～Mar 2025）, we retrospectively analyzed 100 who did not receive immediate surgery after excluding 13 with cardiopulmonary arrest. Patients were stratified into a criteria group （C；thrombosed/occluded false lumen in the ascending aorta with ascending diameter≦50 mm and false lumen≦11 mm；n＝59） and a non-criteria group （NC；outside these criteria；n＝41）. The primary endpoint was in-hospital mortality；secondary endpoints included aortic-related death, post-discharge events, and associations with imaging/clinical indices.

Results：NC patients were older and more often female, with larger ascending aortas and false lumens （both p＜0.001）. In-hospital mortality was 31.7％ in NC vs 1.7％ in C （p＜0.001）；48-hour mortality in NC was 12.2％, and aortic-related deaths clustered within 4.56±2.99 days （range 1～12）. Seven patients underwent delayed surgery for imaging changes；all survived. Discharge alive occurred in 98.3％（C） and 68.3％（NC）. Among those discharged alive, survival up to 2 years was similar. Low body mass index （BMI） and hemodynamically significant tamponade were associated with in-hospital death in NC.

Conclusions：These data support surgery as the default strategy for AAAD. When surgery is unavoidably deferred, conservative management should be considered only in strictly selected patients, with early hemodynamic/computed tomography （CT） triggers for conversion. In NC patients, the first hospital week is the highest-risk window, and low BMI or tamponade should prompt heightened vigilance and a low threshold for intervention.