Aortenaneurysma 2012 – offen, hybrid oder total endovaskulär?

Zusammenfassung

Minimalinvasive, endovaskuläre Verfahren haben das therapeutische Spektrum in der Gefäßchirurgie in den vergangenen 2 Dekaden maßgeblich verändert. Beinahe in jeder Gefäßprovinz sind mittlerweile solche Techniken etabliert und teilweise auch erste Wahl. Anhand der Behandlung des Aortenaneurysmas lässt sich diese Entwicklung besonders gut nachvollziehen. In dieser Übersicht werden anhand einer elektronischen Medline-Literaturrecherche die aktuellen Entwicklungen für die abdominelle und thorakale Aorta dargestellt und einer kritischen Wertung unterzogen. Infrarenal hat sich die Aortenstentbehandlung (EVAR) in der Elektivsituation als Alternative zur offenen Operation bei geeigneter Morphologie flächendeckend etabliert. Juxta- und suprarenal zeigen die „fenestrierte“ (FEVAR) und die „branched“ Technologie vielversprechende Kurzzeitergebnisse, die Methoden sind aber technisch sehr anspruchsvoll und kostenintensiv. Alternativtechniken wie „Chimney“ oder „Sandwich“ rücken deswegen zunehmend in den Fokus des Interesses. Thorakal sind Stentprothesen (TEVAR) für einige Pathologien mittlerweile erste Wahl, komplexe thorakoabdominelle Aneurysmen können zwar schon komplett endovaskulär behandelt werden, hier hat die offene Chirurgie in spezialisierten Zentren aber nach wie vor einen großen Stellwert.

Abstract

During the past two decades, minimally invasive endovascular procedures have changed therapeutic strategies. Such techniques have now become the method of choice for practically all vascular and aortic pathologies. This development is especially apparent in the treatment of aortic aneurysms. The purpose of this report is to provide a critical review about the current standard of care of abdominal and thoracic aorta based on an electronic Medline literature search. For elective infrarenal aneurysms, endovascular aneurysm repair (EVAR) has become a widely accepted alternative to open repair in cases with appropriate morphology. Currently, fenestrated (FEVAR) or branched endografts offer promising short- and mid-term results in juxtarenal aneurysms, however, these techniques are complex, technically challenging, and expensive. The alternative chimney or sandwich graft technique are becoming more common because they are feasible using standard endografts. Thoracic endovascular aortic repair (TEVAR) is already the gold standard for some descending pathologies. Complex thoracoabdominal aneurysms still require open surgery in centres of excellence, whereby, total endovascular repair or hybrid procedures have proved to be feasible in such specialist centres for selected patients.

Schlüsselwörter

Aortenchirurgie - Aortenaneurysma - Aortenstentprothese

Key words

aortic surgery - aortic aneurysm - aortic stent prosthesis

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