Abdominelle Aortenaneurysmen

Abstract

As a rule aneurysms develop slowly from small to rupture imminent aneurysms. In 80 % of cases they remain free of symptoms and in the majority of cases are therefore only discovered by chance. Women are 4 – 5 times less likely to be affected than men. Clinically relevant aneurysms with a diameter of more than 5 cm occur in 1 % of males under 64 years old. The prevalence increases to 2 – 4 % wih increasing age accompanied by increased comorbidity. The underlying reasons for the development of abdominal aortic aneurysms (AAA) are in most cases unclear. Aneurysms which occur in the infrarenal aorta and also in other locations often have a genetic background and an increased familial occurrence. The prognosis of a ruptured AAA is extremely poor with a hospital fatality rate of 55 % and a total lethality of > 80 % because only some of the patients reach hospital alive. The letality associated with AAA can be reduced by establishing an ultrasound screening program by which AAA can be cost-effectively diagnosed with high reliability, sensitivity and specificity. Routine investigations should include the anterior-posterior measurement, determination of the longitudinal and transverse size as well as a topographical representation of the important efferent vessels. A medical, conservative therapy can be important for patients with small or medium sized aneurysms. The only valid measure against an impending AAA rupture is elective surgical treatment which can be carried out via an open repair of the abdominal aorta with a tube or bifurcated graft or by implantation of a stent-graft. Suitable patient selection and determination of the ideal timing for surgery are based on identification of patients with a special risk of rupture. The value of both procdures has not yet been clearly defined and requires a differentiated diagnosis of the indications.

Kernaussagen

• Aneurysmen entwickeln sich in der Regel langsam von kleinen zu rupturgefährdeten Aneurysmen. Sie bleiben in über 80 % der Fälle klinisch symptomfrei und werden deshalb meist nur zufällig entdeckt. Frauen sind 4- bis 5-mal seltener betroffen als Männer.

• Klinisch bedeutsame Aneurysmen mit einem Querdurchmesser von mehr als 5 cm kommen bei 1 % der Männer unter 64 Jahren vor. Mit zunehmendem Alter steigt die Prävalenz auf 2 – 4 % an, vergesellschaftet mit einer erhöhten Komorbidität.

• Die zugrunde liegenden Ursachen für die Entwicklung eines AAA sind in den meisten Fällen unklar. Aneurysmen, die neben der infrarenalen Aorta auch an anderen Lokalisationen auftreten, haben oft eine genetische Ursache und treten familiär gehäuft auf.

• Die Prognose des rupturierten AAA ist mit einer Krankenhausletalität von 55 % extrem schlecht. Die Gesamtletalität liegt bei > 80 %, da nur ein Teil der Patienten das Krankenhaus lebend erreicht.

• Die AAA-assoziierte Letalität kann durch die Etablierung eines Ultraschall-Screening-Programms gesenkt werden, mit dessen Hilfe abdominelle Aortenaneurysmen kosteneffizient und mit hoher Reliabilität, Sensitivität und Spezifität diagnostiziert werden können. Die Routineuntersuchung sollte die anterior-posteriore Ausmessung, die longitudinale und transversale Größenbestimmung sowie die topografische Darstellung zu den wichtigen abgehenden Gefäßen beinhalten.

• Eine medikamentöse und konservative Therapie kann bei Patienten mit kleinen bis mittleren Aneurysmen von Bedeutung sein. Die einzige valide Maßnahme gegen eine drohende AAA-Ruptur ist die elektive operative Therapie des AAA. Sie ist durch einen offenen Ersatz der abdominellen Aorta mittels Rohr- oder Bifurkationsprothese oder durch die Implantation einer Stentprothese möglich. Die adäquate Patientenselektion und die Festlegung des idealen Operationszeitpunkts basiert auf der Identifizierung von Patienten mit einem besonderen Rupturrisiko.

• Der Stellenwert beider Verfahren ist noch nicht klar definiert und erfordert eine differenzierte Indikationsstellung.

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