Das thorakale Aortenaneurysma – Diagnostik und Behandlungsstrategien

Was ist neu?

Diagnostik Die CTA hat sich mit der kontinuierlichen Verbesserung der Qualität, Geschwindigkeit und Verfügbarkeit als optimales diagnostisches Verfahren für die thorakale Aorta etabliert. Daneben gewinnt die MRT zunehmend an Wichtigkeit, hauptsächlich wegen der exakten Darstellung von Wandveränderungen der Aorta und der Möglichkeit, durch innovative Protokolle dynamische Fluss-Phänomene abzubilden.

Behandlungsstrategien Nachdem sich die TEVAR als Therapie der Wahl für die Versorgung von thorakalen Aortenpathologien durchgesetzt hat, fokussiert sich die Entwicklung dieser Technik nun auf den total endovaskulären Ansatz durch die Rekrutierung einer suffizienten proximalen Landezone im Aortenbogen, proximal der LSA mittels gebranchter oder fenestrierter Aortenbogen-Prothesen, die supraaortale Gefäße mit einbeziehen. Da neurologische Komplikationen wie der perioperative Schlaganfall oder die spinale Ischämie derzeit die größte Herausforderung bei endovaskulären Verfahren darstellen, ist intensive Forschung und stetige Optimierung der Techniken die Grundlage für eine sichere endovaskuläre Zukunft in der Versorgung thorakaler Aortenpathologien.

Abstract

Thoracic aortic aneurysms are a relatively uncommon disease, with an incidence of 10.4/100 000, with an increase in the last decades, due to the increased quality of vascular screening. Several imaging techniques like thoracic radiography, echocardiography, magnetic resonance (MRI) or positron emission tomography (PET) can be used for the diagnosis of such condition, whose first diagnosis is usually incidental. The gold standard for aneurysm evaluation is computed tomography angiography (CTA), which allows precise diameter assessment and accurate preoperative planning. Advancements in imaging techniques, through electrocardiography (ECG)-gated CTA, permit to avoid movement artifacts and have a more precise definition of proximal aortic segments (aortic arch, ascending aorta).

The urgent or emergent treatment of thoracic aneurysms is indicated in symptomatic patients and in case of rupture, respectively. The current European Society for Vascular Surgery guidelines recommend the elective treatment of thoracic aneurysms with a diameter > 55 mm, since diameters of 55 – 60 mm are associated with a rupture risk of 10 %/year. Lower perioperative morbidity and mortality rates have been demonstrated for endovascular repair in comparison with open surgery. According to the current guidelines, the treatment of choice is endovascular, through the implantation of an aortic stent graft (thoracic endovascular aortic repair, TEVAR), while open surgery is reserved to young patients, fit for open surgery. Hybrid procedures, introduced in 2000, include the debranching of supra aortic vessels and TEVAR and are a well established procedure for the treatment of aneurysms involving the aortic arch. The increasing research and expertise in endovascular surgery lead to the development of complex procedures, like chimney TEVAR, fenestrated and branched TEVAR which allowed to reach proximal landing zone to the ascending aorta.

Schlüsselwörter

Thorakales Aortenaneurysma - Endoprothese - endovaskuläre Versorgung - offene Chirurgie - Hybridverfahren

Key words

thoracic aortic aneurysm - endograft - endovascular repair - open surgery - hybrid procedures

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