Das rupturierte abdominale Aortenaneurysma – Ergebnisse und prognostische Faktoren an einem gefäßchirurgischen Zentrum

Zusammenfassung

Einleitung: Trotz des optimierten perioperativen Managements über die letzten Jahrzehnte hat sich die Prognose der Patienten mit rupturiertem abdominalem Aortenaneurysma (rAAA) nicht wesentlich verbessert. Ziel dieser retrospektiven Studie war, prä-, intra- und postoperative Faktoren zu identifizieren, die das perioperative und das langfristige Outcome der Patienten beeinflussen und die iatrogen beeinflussbar wären.

Methoden: Es erfolgte die retrospektive Datenanalyse von 49 Patienten, welche zwischen Anfang 2006 und Ende 2012 an einem gefäßchirurgischen Zentrum wegen eines rAAA operiert worden sind. Der Mindest-Follow-up betrug 30 Monate. Die statistischen Analysen erfolgten univariat mit der Kaplan-Meier-Methode und dem Log-Rank-Test, multivariat mit dem Cox-Modell.

Ergebnisse: Die intrahospitale Mortalität lag bei 40,8 %. Die 30-Tage-Letalität lag bei 28,9 %, die 1-Jahres-Überlebensrate bei 52,4 % und die 5-Jahres-Überlebensrate bei 45,3 %. In der univariaten Analyse bestanden signifikante Unterschiede bei der frühpostoperativen Überlebenswahrscheinlichkeit in Abhängigkeit von dem präoperativen systolischen RR-Wert, dem präoperativen Hb-Wert (< 10 vs. ≥ 10 g/dl), dem intraoperativen Transfusionsbedarf, der Rupturform, der Aneurysmalokalisation, der Notwendigkeit chirurgischer Folgeeingriffe, von postoperativem Multiorganversagen (MOV) und akutem Nierenversagen (ANV) sowie der postoperativen Sepsis. Bei den vollständig erfassten entlassenen Patienten (n = 27) hatten nur die Rupturform, die Aneurysmalokalisation, die präexistente KHK oder Diabetes mellitus einen signifikanten Einfluss auf die Langzeitüberlebenswahrscheinlichkeit. In der multivariaten Analyse nach dem Cox-Modell hatten Patienten mit einer vorbestehenden KHK ein 3,9-fach und mit einer freien Perforation ein 10-fach erhöhtes relatives Risiko, nach der Operation des rAAA zu versterben.

Schlussfolgerung: Die hohe Sterblichkeit des rAAA wird durch den hämorrhagischen Schock mit vorrangig nicht chirurgischen Komplikationen verursacht. Die therapeutischen Anstrengungen sollten sich auf die perioperativen Einflussfaktoren konzentrieren, welche sich optimieren lassen. Neben der Zentralisierung der rAAA-Versorgung in gefäßchirurgischen „high-volume“-Einrichtungen spielt das systematische Ultraschall-Screening der Bevölkerung über 65 Jahre eine bedeutende Rolle. Ein möglicher Vorteil der endovaskulären Aneurysmaausschaltung (EVAR) beim rAAA muss durch laufende Studien, z. B. IMPROVE, RCAR, AJAX, noch bewiesen werden.

Abstract

Introduction: Although the perioperative management has been optimised over the past few decades, there has not been a remarkable improvement in the mortality rates of patients with a ruptured abdominal aortic aneurysm (rAAA). The aim of this retrospective trial was to define pre-, intra- and postoperative parameters which influence the perioperative and long-term outcome of patients and which can be modified by the operating team.

Methods: A retrospective database analysis was performed in 49 patients who had undergone an operation of rAAA in our certified centre of vascular surgery between the beginning of 2006 and the end of 2012. The minimal follow-up period was 30 months. The statistical analysis was done univariately using the Kaplan-Meier method and a log-rank-test, and multivariately with the Cox model.

Results: Intrahospital mortality was 40.8 %, perioperative mortality (30 postoperative days) was 28.9 %. The survival rate for 1 year was 52.4 %; the survival rate for 5 years was 45.3 %. In the univariate analysis, significant differences in the early postoperative survival rates were found depending on preoperative systolic blood pressure, preoperative haemoglobin (< 10 vs. ≥ 10 g/dl), the intraoperative need of blood and frozen plasma transfusions, type of perforation, type of AAA, the need for further surgical interventions, postoperative MOF, acute kidney failure and postoperative septicaemia. The late survival rates were significantly influenced by the type of perforation and AAA, pre-existing coronary disease and diabetes mellitus in fully identified patients discharged from hospital (n = 27). In the multivariate analysis pursuant to the Cox model, patients with pre-existing coronary disease had a 3.9-fold higher relative risk to die after the operation of rAAA, while patients with a free perforation of the rAA had a 10-fold higher relative risk.

Conclusion: The high mortality of rAAA is caused by haemorrhagic shock and its complications, which are mostly non-surgical. Therapeutic efforts should focus on those perioperative parameters which can be modified by the treating teams. Alongside the centralisation of rAAA in high-volume-departments of vascular surgery, the systematic sonographic screening for asymptomatic AAA in the population older than 65 years should be enforced. A possible advantage of EVAR in rAAA has yet to be shown by trials in progress such as IMPROVE, AJAX and RCAR.

Schlüsselwörter

rupturiertes abdominales Aortenaneurysma - Prognosefaktoren - Ergebnisse

Key words

ruptured abdominal aortic aneurysm - prognostic factors - outcome

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