Elektive Therapie des asymptomatischen infrarenalen Aortenaneurysmas

Zusammenfassung

Die endovaskuläre Operation des infrarenalen Aortenaneurysmas (EVAR) hat sich in den letzten Jahren als Alternative etabliert und ist aus dem Spektrum eines Gefäßchirurgen nicht mehr wegzudenken. Die perioperative Morbidität ist mit Sicherheit, wie in vielen Studien belegt, deutlich geringer als bei der offenen Operation. Auch die offene Operation zeigt im Langzeitverlauf Komplikationen wie Ruptur oder aorto-enterale Fisteln, die risikobehaftete Sekundäroperationen erforderlich machen. Bezüglich der Letalität gibt es einige valide Studien, die für EVAR eine signifikant niedrigere Sterblichkeit belegen im Vergleich zu dem offenen Vorgehen. Diese wurden durch das Erscheinen der Ergebnisse der UK- EVAR trial1 mit hohem Evidenzgrad bestätigt, die Ergebnisse der beiden anderen noch laufenden randomisierten Studien stehen noch aus.

Sollte sich in diesen Studien die niedrigere Morbiditäts-/Letalitätsrate für EVAR bestätigen, muss über die Indikationsstellung für das Aortenaneurysma hinsichtlich des Risikoprofils und des Maximaldurchmessers neu nachgedacht werden.

Die endovaskuläre Operation hat als Unsicherheit, die bisher noch nicht vorhandenen Langzeitergebnisse. Es muss derzeit deshalb auch noch eine intensive Nachbeobachtung der endovaskulär behandelten Patienten gefordert werden. Die Endoleaks stellen bei geeigneter Indikationsstellung und bei den neuen Gefäßprothesen kein unlösbares Problem mehr dar.

Die beiden Verfahren sollten nicht konkurrierend, sondern ergänzend im Spektrum jeden Gefäßzentrums angeboten werden.

Summary

In recent years, endovascular operations on infrarenal aortic aneurysm (EVAR) have not only been acknowledged as an alternative, but have become an indispensable „tool of the trade” for the vascular surgeon. As documented in many studies, perioperative morbidity is definitely much lower than in open surgery. In the long term, open surgery is also subject to complications such as rupture or aorto-enteral fistulae which necessitate secondary operations with their associated risks. There are some valid studies documenting a significantly lower mortality for EVAR than for open surgery. These datas were recently confirmed with high evidence level by the published results of UK-EVAR trial 1. The other randomized trials are currently ongoing.

If the lower morbidity and lethality rate for EVAR is confirmed in these studies, the establishment of the indication for aortic aneurysm must be reconsidered with regard to the risk profile and the maximum diameter.

The fact that long-term results are not yet available for the endovascular operation introduces a factor of uncertainty. Intensive follow-up observation is therefore an absolute prerequisite in patients who have undergone endovascular treatment. If the establishment of the indication is appropriate, with the new vascular prosthesis endoleaks are no longer an insoluble problem. The two methods should not be regarded as mutually competitive, but as complementary components of the treatment spectrum at every vascular center.

1 Herrn Prof. Dr. med. habil. Martin Bartel, emer. Ordinarius für Thorax- und Gefäßchirurgie der Friedrich-Schiller-Universität Jena, in Anerkennung seiner Person und seiner großen Verdienste für die Gefäßchirurgie gewidmet

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1 Herrn Prof. Dr. med. habil. Martin Bartel, emer. Ordinarius für Thorax- und Gefäßchirurgie der Friedrich-Schiller-Universität Jena, in Anerkennung seiner Person und seiner großen Verdienste für die Gefäßchirurgie gewidmet