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Gefäßmedizin Scan - Zeitschrift für Angiologie, Gefäßchirurgie, diagnostische und interventionelle Radiologie 2021; 8(04): 287-298
DOI: 10.1055/a-1666-3096
CME-Fortbildung

Risikobewertung und Management der Typ-B-Aortendissektion

Martin Czerny
,
Christoph Nienaber
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Die akute Typ-B-Dissektion – ein potenziell lebensbedrohliches Krankheitsbild. Entscheidend für das Outcome der Patienten sind eine schnelle und zielführende, standardisierte Diagnostik zur Klassifikation der Dissektion und Definition der Hochrisikopatienten, um den entsprechenden Behandlungspfad einschlagen zu können.
Kernaussagen

  • Die Inzidenz der wirklich unkomplizierten Typ-B-Dissektion ist geringer als bisher vermutet.

  • Eine schrittweise Diagnostik zur Bestätigung oder zum Ausschluss von „High-Risk“-Surrogaten sollte anhand einer CT-Angiografie durchgeführt werden, bevor die Diagnose „unkompliziert“ etabliert wird.

  • Das Potenzial der Aorta zum positiven Remodeling (Durchmesserabnahme, Approximierung der Wandschichten) nimmt mit der Zeit ab, dies sollte man bei der Wahl des Behandlungszeitpunkts mit einbeziehen („window of opportunity of 90 days“).

  • Das Beachten der weitestmöglichen Aufrechterhaltung der Rückenmarkperfusion über die 4 arteriellen Hauptzuflüsse stellt einen entscheidenden Faktor für die Reduktion des Restrisikos für eine symptomatische Rückenmarkischämie dar.

  • Die Liquordrainage ist eine hocheffektive Maßnahme zur Vorbeugung und auch zur Therapie symptomatischer Rückenmarksischämien.

  • Bei Patienten, die eine Behandlung benötigen, jedoch ein hohes Risiko für eine retrograde Typ-A-Dissektion haben, sollte die FET-Technik in Betracht gezogen werden.



Publication History

Article published online:
30 November 2021

© 2021. Thieme. All rights reserved.

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  • Literatur

  • 1 Czerny M, Schmidli J, Adler S. et al. Current options and recommendations for the treatment of thoracic aortic pathologies involving the aortic arch: an expert consensus document of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Vascular Surgery (ESVS). Eur J Cardiothorac Surg 2019; 55: 133-162
    CrossrefPubMedGoogle Scholar
  • 2 Loewe C, Czerny M, Sodeck GH. et al. A new mechanism by which an acute type B aortic dissection is primarily complicated, becomes complicated, or remains uncomplicated. Ann Thorac Surg 2012; 93: 1215-1222
    CrossrefPubMedGoogle Scholar
  • 3 Ante M, Mylonas S, Skrypnik D. et al. Prevalence of the computed tomographic morphological DISSECT predictors in uncomplicated Stanford type B aortic dissection. Eur J Vasc Endovasc Surg 2018; 56: 525-533
    CrossrefPubMedGoogle Scholar
  • 4 Weiss G, Wolner I, Folkmann S. et al. The location of the primary entry tear in acute type B aortic dissection affects early outcome. Eur J Cardiothorac Surg 2012; 42: 571-576
    CrossrefPubMedGoogle Scholar
  • 5 Erbel R, Aboyans V, Boileau C. et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases - Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult - The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 35: 2873-2926
    CrossrefPubMedGoogle Scholar
  • 6 Rylski B, Reser D, Kari F. et al. Acute Non A, non B aortic dissection: definition, treatment and outcome. Eur J Cardiothorac Surg 2017; 52: 1111-1117
    CrossrefPubMedGoogle Scholar
  • 7 Grimm M, Loewe C, Gottardi R. et al. Novel insights into the mechanisms and treatment of intramural hematoma affecting the entire thoracic aorta. Ann Thorac Surg 2008; 86: 453-456
    CrossrefPubMedGoogle Scholar
  • 8 Trimarchi S, Jonker FH, van Bogerijen GH. et al. Predicting aortic enlargement in type B aortic dissection. Ann Cardiothorac Surg 2014; 3: 285-291
    PubMedGoogle Scholar
  • 9 Czerny M, Eggebrecht H, Rousseau H. et al. Distal stent-graft induced new entry after TEVAR or FET: insights into a new disease from EuREC. Ann Thorac Surg 2020; 110: 1494-1500
    CrossrefPubMedGoogle Scholar
  • 10 Tsai TT, Evangelista A, Nienaber CA. et al. Partial thrombosis of the false lumen in patients with acute type B aortic dissection. N Engl J Med 2007; 357: 349-359
    CrossrefPubMedGoogle Scholar
  • 11 Evangelista A, Isselbacher EM, Bossone E. et al. Insights from the International Registry of Acute Aortic Dissection: A 20 year experience of collaborative clinical research. Circulation 2018; 137: 1846-1860
    CrossrefPubMedGoogle Scholar
  • 12 Czerny M, Rodler S, Fakhimi S. et al. Mid-term results of TEVAR in patients with aneurysms involving the descending aorta originating from chronic type B dissections. Ann Thorac Surg 2010; 90: 90-94
    CrossrefPubMedGoogle Scholar
  • 13 Pape LA, Awais M, Woznicki EM. et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection. J Am Coll Cardiol 2015; 66: 350-358
    CrossrefPubMedGoogle Scholar
  • 14 Zeeshan A, Woo EY, Bavaria JE. et al. Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy. J Thorac Cardiovasc Surg 2010; 140 (Suppl. 06) S109-115
    CrossrefPubMedGoogle Scholar
  • 15 Nienaber C, Rousseau H, Eggebrecht H. et al. A randomized comparison of strategies for noncomplicated type B aortic dissection - the INvestigation of STEnt-grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009; 120: 2519-2528
    CrossrefPubMedGoogle Scholar
  • 16 Nienaber CA, Kische S, Rousseau H. et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Intervent 2013; 6: 407-416
    CrossrefPubMedGoogle Scholar
  • 17 Brunkwall J, Kasprzak P, Verhoeven E. et al. Endovascular repair of acute uncomplicated aortic type B dissection promotes aortic remodeling ; 1 year results of the ADSORB trial. Eur J Vasc Endovasc Surg 2014; 48: 285-291
    CrossrefPubMedGoogle Scholar
  • 18 Moulakakis KG, Mylonas SN, Dalainas I. et al. Management of complicated and uncomplicated acute type B dissection. A systematic review and meta-analysis. Ann Cardiothorac Surg 2014; 3: 234-246
    CrossrefPubMedGoogle Scholar
  • 19 Grabenwöger M, Alfonso F, Bachet J. et al. ESC/EACTS position statement on thoracic endovascular aortic repair (TEVAR). Eur J Cardiothorac Surg 2012; 42: 17-24
    CrossrefPubMedGoogle Scholar
  • 20 Evangelista A, Salas A, Ribera A. et al. Long-term outcome of aortic dissection with patent false lumen: predictive role of entry tear size and location. Circulation 2012; 125: 3133-3141
    CrossrefPubMedGoogle Scholar
  • 21 Codner JA, Lou X, Duwayri YM. et al. The distance of the primary intimal tear from the left subclavian artery predicts aortic growth in uncomplicated type B aortic dissection. J Vasc Surg 2019; 69: 692-700
    CrossrefPubMedGoogle Scholar
  • 22 Song JM, Kim SD, Kim JH. et al. Long-term predictors of descending aorta aneurysmal change in patients with aortic dissection. J Am Coll Cardiol 2007; 50: 799-804
    CrossrefPubMedGoogle Scholar
  • 23 Fattori R, Cao P, De Rango P. et al. Interdisciplinary expert consensus document on endovascular treatment of type B aortic dissection. J Am Coll Cardiol 2013; 61: 1661-1678
    CrossrefPubMedGoogle Scholar
  • 24 Lou X, Duwayri YM, Jordan Jr WD. et al. The Safety and Efficacy of Extended TEVAR in Acute Type B Aortic Dissection. Ann Thorac Surg 2020; 110: 799-806
    CrossrefPubMedGoogle Scholar
  • 25 Cochennec F, Tresson P, Cross J. et al. Hybrid repair of aortic arch dissections. J Vasc Surg 2013; 57: 1560-1567
    CrossrefPubMedGoogle Scholar
  • 26 Eggebrecht H, Thompson M, Rousseau H. et al. Retrograde ascending aortic dissection during or after thoracic aortic stent-graft placement - insights from the European Registry on endovascular aortic repair complications (EuREC). Circulation 2009; 120: S276-281
    CrossrefPubMedGoogle Scholar
  • 27 Czerny M, Eggebrecht H, Sodeck G. et al. Mechanisms of symptomatic spinal cord ischemia after TEVAR - Insights from the European Registry of Endovascular Aortic Repair Complications (EuREC). J Endovasc Ther 2012; 19: 37-43
    CrossrefPubMedGoogle Scholar
  • 28 Etz CD, Kari FA, Mueller CS. et al. The collateral network concept: remodeling of the arterial collateral network after experimental segmental artery sacrifice. J Thorac Cardiovasc Surg 2011; 141: 1029-1036
    CrossrefPubMedGoogle Scholar
  • 29 Heber U, Mayrhofer M, Gottardi R. et al. The intraspinal arterial collateral network: a new anatomical basis for understanding and preventing paraplegia during aortic repair. Eur J Cardiothorac Surg 2021; 59: 137-144
    CrossrefPubMedGoogle Scholar
  • 30 Etz C, Weigang E, Hartert M. et al. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: A position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery. Eur J Cardiothorac Surg 2015; 47: 943-957
    CrossrefPubMedGoogle Scholar
  • 31 Maier S, Shcherbakova M, Beyersdorf F. et al. Benefits and risks of prophylactic cerebro-spinal fluid catheter and evoked potential monitoring in symptomatic spinal cord ischemia low-risk thoracic endovascular aortic repair. Thorac Cardiovasc Surg 2018; 67: 379-384
    PubMedGoogle Scholar
  • 32 Kreibich M, Berger T, Morlock J. et al. The frozen elephant trunk technique for the treatment of acute complicated type B aortic dissection. Eur J Cardiothorac Surg 2018; 53: 525-530
    CrossrefPubMedGoogle Scholar
  • 33 Desai ND, Gottret JP, Szeto WY. et al. Impact of timing on major complications after thoracic endovascular aortic repair for acute type B aortic dissection. J Thorac Cardiovasc Surg 2015; 149 : S151-156
    CrossrefPubMedGoogle Scholar