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.