Remote ischemic Conditioning – endogene Gewebeprotektion und ihre Einsatzmöglichkeiten in der Chirurgie

Zusammenfassung

Als Grundlage für Wundheilung und Regeneration nach Operationen kommt der Gewebeperfusion zentrale Bedeutung zu. Ischämien und Reperfusion führen über die Auslösung von Entzündungsreaktionen im Gewebe zu Gewebeschäden bis hin zur Nekrose. Um im Rahmen des perioperativen Managements das Gewebe vor solch schädigenden Einflüssen zu schützen, wurden eine Vielzahl an Konditionierungsverfahren beschrieben. Die wenigsten dieser Verfahren erfüllen jedoch die Forderung nach Wirksamkeit, zeit- und kosteneffektiver Anwendbarkeit und nicht invasiver Anwendung ohne zusätzliche Geräte oder Medikamente. Remote ischemic Conditioning (RIC) stellt eine Möglichkeit der endogenen Gewebekonditionierung dar, welche diese Kriterien erfüllt. Durch kurze wiederholte Zyklen aus Ischämie und Reperfusion eines isolierten vaskulären Territoriums kommt es über die Aktivierung körpereigener Signalwege zu gesteigerter Toleranz gegenüber Minderversorgung und Begrenzung des Reperfusionsschadens im Gewebe auch fernab des eigentlich konditionierten Gebiets. Zur nicht invasiven Applikation der notwendigen Ischämie-/Reperfusionszyklen genügt eine Druckmanschette, die am Oberarm angelegt und wiederholt auf suprasystolische Werte aufgepumpt wird. Die verschiedenen Konzepte des Remote ischemic Pre-, Per- und Postconditioning ermöglichen die Anwendung sowohl im Rahmen von Elektiveingriffen als auch bei Notfallinterventionen. RIC findet, aufbauend auf vielversprechenden experimentellen Studien, zunehmend klinische Anwendung. Neben Studien zur Kardio-, Nephro- und Neuroprotektion liegen auch erste Ergebnisse für den potenziellen Einsatz von RIC in der rekonstruktiven Mikrochirurgie vor. Dieser Artikel soll daher einen Überblick über Entwicklung, Konzepte und beteiligte Mechanismen des RIC mit Schwerpunkt auf den Einsatzmöglichkeiten in der Chirurgie geben.

Abstract

Tissue perfusion is pivotal to wound healing and tissue regeneration after surgery. Ischemia and reperfusion lead to inflammatory reactions with consecutive tissue damage and necrosis. Multiple conditioning techniques have been described to protect tissue from those damaging mechanisms in the perioperative period. However, most of these fail to meet the requirements of a good therapeutic effect, time and cost efficiency, non-invasiveness and applicability without the need for additional devices or drugs. Remote ischemic conditioning (RIC) is a technique to provide endogenous tissue protection, which fully meets those requirements. Repeated, short cycles of ischemia/reperfusion applied to a circumscribed vascular territory lead to the activation of endogenous signal pathways resulting in increased tolerance to hypoperfusion and limiting the damage caused by reperfusion, even in tissues located far away from the conditioned area. The non-invasive application of the conditioning stimulus requires no more than a pressure cuff, which is placed on the upper arm and is repeatedly inflated to suprasystolic pressures. Different concepts of remote ischemic pre-, peri- and postconditioning enable the usage in both elective and emergency surgical interventions. Based on encouraging experimental studies, the application of RIC has increased in the clinical setting. In addition to studies addressing cardio-, nephro- or neuroprotection there are some initial findings supporting a potential beneficial application in reconstructive microsurgery. This article aims to give an overview of the development, concepts and mechanisms of RIC with a focus on its clinical application in the field of surgery.

Schlüsselwörter

Remote ischemic Conditioning - endogene Gewebeprotektion - Durchblutung - Ischämie-/Reperfusionsschaden

Key words

remote ischemic conditioning - perfusion - endogenous tissue protection - ischemia/reperfusion injury

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