Management des akuten Aortensyndroms

Abstract

Acute aortic syndrome (AAS) comprises various pathological potential life-threatening conditions. These conditions include aortic dissection, intramural haematoma (IMH) of the aorta, and penetrating aortic ulcer (PAU), as well as symptomatic aortic aneurysm. Acute aortic dissection is an uncommon but lethal cause of acute chest, back and abdominal pain.

Timely diagnosis is paramount as mortality due to acute aortic dissection rises by approximately 1 – 2 % per hour. Diagnostic imaging modalities that may be used for this condition are transthoracic and transesophageal echocardiography, CT, MRT and angiography in combination with intravascular ultrasound (IVUS). Patients presenting with AAS require immediate diagnosis for rapid initiation of adequate therapeutic measures. Acute type A aortic dissections generally require surgery, uncomplicated type B dissections are primarily treated using conservative therapy, and complicated type B dissections can be primarily treated with stent-graft implantation. Potential severe complications of AAS include aneurysm formation that may cause aortic rupture; cardiogenic shock due to pericardial tamponade or high-grade aortic insufficiency; and malperfusion with ischaemic damage to vital organs supplied by the thoracoabdominal aorta. All these complications greatly increase the overall risk of aortic dissection.

Kernaussagen

• Unter dem „akuten Aortensyndrom“ werden potenziell lebensbedrohliche Erkrankungen der Aorta, wie z. B. die klassische Aortendissektion, das intramurale Hämatom, das penetrierende Aortenulkus und symptomatische Aortenaneurysmen zusammengefasst.

• Sie alle können sich klinisch sehr ähnlich sein, ineinander übergehen und erfordern in der Regel eine rasche Therapieeinleitung.

• Leitsymptom sind plötzlich auftretende Thorax- und/oder Rückenschmerzen (seltener auch Bauchschmerzen).

• Wesentliche bildgebende Verfahren sind transthorakale und transösophageale Echokardiografie, CT, MRT und Angiografie in Kombination mit dem intravaskulären Ultraschall (IVUS).

• Die diagnostischen Mittel sollten abhängig von der zeitlichen Verfügbarkeit und der Expertise des jeweiligen Herz- und Gefäßzentrums gewählt werden, um eine schnellstmögliche Diagnosestellung und Therapieeinleitung gewährleisten zu können.

• Das Prozedere ist im Wesentlichen abhängig von der Lokalisation der Dissektion, der hämodynamischen Stabilität des Patienten sowie aufgetretenen oder drohenden Komplikationen.

• Die Versorgung der Typ-A-Aortendissektion erfolgt primär chirurgisch, während die unkomplizierte Typ-B-Aortendissektion konservativ und die komplizierte Typ-B-Dissektion primär interventionell mittels Aortenstentgraft behandelt wird.

• Therapieziel ist die Vermeidung einer Ruptur, einer zerebralen, intestinalen oder peripheren Malperfusion, sowie langfristig einer weiteren aneurysmatischen Umformung der Aorta.

• Alle Patienten mit Aortendissektion sollten engmaschig mittels TTE und CT oder MRT kontrolliert werden.

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