Download PDF
Gefäßmedizin Scan - Zeitschrift für Angiologie, Gefäßchirurgie, diagnostische und interventionelle Radiologie 2015; 02(01): 71-87
DOI: 10.1055/s-0034-1391650
Fortbildung
© Georg Thieme Verlag KG Stuttgart · New York

Das abdominale Aortenaneurysma

Teil II: Therapie
C.-A. Behrendt
,
H. C. Rieß
,
F. Heidemann
,
T. Kölbel
,
R. T. Grundmann
,
E. S. Debus
Further Information

Publication History

Publication Date:
17 February 2015 (online)

Also available at
    Permissions and Reprints
Fazit

Die Entscheidung zur Therapie des AAA orientiert sich an der Aneurysmagröße und dem Rupturrisiko und sollte das individuelle Operationsrisiko berücksichtigen. Bei asymptomatischen AAA besteht die Indikation zur Operation ab 5,5 cm (Männer), da in dieser Situation das Rupturrisiko das Operationsrisiko übersteigt. Frauen sollten bereits bei Nachweis eines AAA über 5,2 cm gefäßchirurgisch evaluiert werden.

Für die Therapie des AAA stehen konservativ-medikamentöse, offen-chirurgische und endovaskuläre Verfahren teilweise komplementär zur Verfügung; die Therapieplanung sollte interdisziplinär erfolgen und alle Begleitumstände erfassen.

Die Spezialisierung und das Fallaufkommen korrelieren signifikant mit dem Behandlungsergebnis. Die Behandlung komplexer Fälle sollte daher spezialisierten Zentren mit einem hohen Fallaufkommen vorbehalten bleiben.

Die EVAR zeigt gegenüber der OAR periprozedural und im postoperativen Verlauf eine geringere Letalität, die sich nach etwa 2 – 3 Jahren jedoch angleicht.

Vor allem die offene Aortenchirurgie gehört zu den Hochrisikoeingriffen. Zur präoperativen Risikoeinschätzung vor elektiven Aorteneingriffen stehen verschiedene valide Score-Systeme (z. B. BAR-Score) zur Verfügung. Mindestvoraussetzungen an die Anatomie des AAA müssen vor der Entscheidung zur endovaskulären Therapie geprüft werden. Dazu zählen u. a. ein ausreichender Aneurysmahals, ein geeigneter Alpha- und Beta-Winkel sowie die sorgfältige Evaluation der Iliakal- und Zugangsgefäße.

Abweichungen von den Instructions for Use müssen dokumentiert werden.

 

  • Literatur

  • 1 Böhmer AB, Wappler F, Zwißler B. Preoperative Risk Assessment #8212; from routine tests to individualized investigation. Dtsch Arztebl International 2014; 111: 437-446
    Google Scholar
  • 2 Dua A, Algodi MM, Furlough C et al. Development of a scoring system to estimate mortality in abdominal aortic aneurysms management. Vascular 2014; pii: 1708538114563825 [Epub ahead of print]
    Google Scholar
  • 3 Grant SW, Hickey GL, Carlson ED et al. Comparison of three contemporary risk scores for mortality following elective abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2014; 48: 38-44
    Google Scholar
  • 4 Dua A, Kuy S, Lee CJ et al. Epidemiology of aortic aneurysm repair in the United States from 2000 to 2010. J Vasc Surg 2014; 59: 1512-1517
    CrossrefGoogle Scholar
  • 5 Debus ES, Nüllen H, Torsello G et al. Zur Behandlung des abdominellen Aortenaneurysmas in Deutschland. Gefässchirurgie 2014; 19: 412-421
    CrossrefGoogle Scholar
  • 6 Moll FL, Powell JT, Fraedrich G et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 (Suppl. 01) 1-S58
    CrossrefGoogle Scholar
  • 7 Hirsch AT, Haskal ZJ, Hertzer NR et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113: e463-e654
    CrossrefPubMedGoogle Scholar
  • 8 Powell JT, Greenhalgh RM. Clinical practice. Small abdominal aortic aneurysms. N Engl J Med 2003; 348: 1895-1901
    CrossrefGoogle Scholar
  • 9 Greenhalgh RM, Brown LC. United Kingdom EVAR Trial Investigators et al. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010; 362: 1863-1871
    CrossrefGoogle Scholar
  • 10 Lederle FA, Freischlag JA, Kyriakides TC et al. Long-term comparison of endovascular and open repair of abdominal aortic aneurysm. N Engl J Med 2012; 367: 1988-1997
    CrossrefGoogle Scholar
  • 11 Lederle FA, Johnson GR, Wilson SE et al. Prevalence and associations of abdominal aortic aneurysm detected through screening. Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Group. Ann Intern Med 1997; 126: 441-449
    CrossrefGoogle Scholar
  • 12 Galiñanes EL, Reynolds S, Dombrovskiy VY et al. The impact of preoperative statin therapy on open and endovascular abdominal aortic aneurysm repair outcomes. Vascular 2014; pii: 1708538114552837 [Epub ahead of print]
    Google Scholar
  • 13 Kertai MD, Boersma E, Westerhout CM et al. Association between long-term statin use and mortality after successful abdominal aortic aneurysm surgery. Am J Med 2004; 116: 96-103
    CrossrefGoogle Scholar
  • 14 Schouten O, van Laanen JH, Boersma E et al. Statins are associated with a reduced infrarenal abdominal aortic aneurysm growth. Eur J Vasc Endovasc Surg 2006; 32: 21-26
    CrossrefGoogle Scholar
  • 15 Sukhija R, Aronow WS, Sandhu R et al. Mortality and size of abdominal aortic aneurysm at long-term follow-up of patients not treated surgically and treated with and without statins. Am J Cardiol 2006; 97: 279-280
    CrossrefGoogle Scholar
  • 16 Takagi H, Mizuno Y, Yamamoto H et al. Alice in Wonderland of statin therapy for small abdominal aortic aneurysm. Int J Cardiol 2013; 166: 252-255
    CrossrefGoogle Scholar
  • 17 Dunne JA, Bailey MA, Griffin KJ et al. Statins: the holy grail of Abdominal Aortic Aneurysm (AAA) growth attenuation? A systematic review of the literature. Curr Vasc Pharmacol 2014; 12: 168-172
    CrossrefGoogle Scholar
  • 18 Gray C, Goodman P, O’Malley MK et al. Statins promote residual aneurysm sac regression following endovascular aortic aneurysm repair. Vasc Endovascular Surg 2014; 48: 111-115
    CrossrefGoogle Scholar
  • 19 Gadowski GR, Pilcher DB, Ricci MA. Abdominal aortic aneurysm expansion rate: effect of size and beta-adrenergic blockade. J Vasc Surg 1994; 19: 727-731
    CrossrefGoogle Scholar
  • 20 Rughani G, Robertson L, Clarke M. Medical treatment for small abdominal aortic aneurysms. Cochrane Database Syst Rev 2012; 9 CD009536
    Google Scholar
  • 21 Libby P. Inflammation in atherosclerosis. Nature 2002; 420: 868-874
    CrossrefPubMedGoogle Scholar
  • 22 Lindholt JS, Juul S, Vammen S et al. Immunoglobulin A antibodies against Chlamydia pneumoniae are associated with expansion of abdominal aortic aneurysm. Br J Surg 1999; 86: 634-638
    CrossrefGoogle Scholar
  • 23 Høgh A, Vammen S, Ostergaard L et al. Intermittent roxithromycin for preventing progression of small abdominal aortic aneurysms: long-term results of a small clinical trial. Vasc Endovascular Surg 2009; 43: 452-456
    CrossrefGoogle Scholar
  • 24 Bickenbach KA, Karanicolas PJ, Ammori JB et al. Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery. Am J Surg 2013; 206: 400-409
    CrossrefGoogle Scholar
  • 26 Twine CP, Lane IF, Williams IM. The retroperitoneal approach to the abdominal aorta in the endovascular era. J Vasc Surg 2012; 56: 834-838
    CrossrefGoogle Scholar
  • 26 Twine CP, Humphreys AK, Williams IM. Systematic review and meta-analysis of the retroperitoneal versus the transperitoneal approach to the abdominal aorta. Eur J Vasc Endovasc Surg 2013; 46: 36-47
    CrossrefGoogle Scholar
  • 27 Mani K, Bjorck M, Wanhainen A. Changes in the management of infrarenal abdominal aortic aneurysm disease in Sweden. Br J Surg 2013; 100: 638-644
    CrossrefGoogle Scholar
  • 28 Trenner M, Haller B, Söllner H et al. 12 Jahre „Qualitätssicherung BAA“ der DGG, Teil I. Gefässchirurgie 2013; 18: 206-213
    CrossrefGoogle Scholar
  • 29 Dimick JB, Cowan Jr JA, Stanley JC et al. Surgeon specialty and provider volumes are related to outcome of intact abdominal aortic aneurysm repair in the United States. J Vasc Surg 2003; 38: 739-744
    CrossrefPubMedGoogle Scholar
  • 30 Hawkins AT, Smith AD, Schaumeier MJ et al. The effect of surgeon specialization on outcomes after ruptured abdominal aortic aneurysm repair. J Vasc Surg 2014; 60: 590-596
    CrossrefGoogle Scholar
  • 31 Dardik A, Lin JW, Gordon TA et al. Results of elective abdominal aortic aneurysm repair in the 1990s: a population-based analysis of 2335 cases. J Vasc Surg 1999; 30: 985-995
    CrossrefPubMedGoogle Scholar
  • 32 Steyerberg EW, Kievit J, de Mol Van Otterloo JC et al. Perioperative mortality of elective abdominal aortic aneurysm surgery. A clinical prediction rule based on literature and individual patient data. Arch Intern Med 1995; 155: 1998-2004
    CrossrefGoogle Scholar
  • 33 Hallin A, Bergqvist D, Holmberg L. Literature review of surgical management of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2001; 22: 197-204
    CrossrefGoogle Scholar
  • 34 Volodos’ NL, Shekhanin VE, Karpovich IP. A self-fixing synthetic blood vessel endoprosthesis. Vestn Khir Im I I Grek 1986; 137: 123-125
    Google Scholar
  • 35 Volodos’ NL, Karpovich IP, Shekhanin VE et al. A case of distant transfemoral endoprosthesis of the thoracic artery using a self-fixing synthetic prosthesis in traumatic aneurysm. Grudn Khir 1988; 6: 84-86
    Google Scholar
  • 36 Antoniou GA, Georgiadis GS, Antoniou SA et al. A meta-analysis of outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile and friendly neck anatomy. J Vasc Surg 2013; 57: 527-538
    CrossrefGoogle Scholar
  • 37 Browne TF, Hartley D, Purchas S et al. A fenestrated covered suprarenal aortic stent. Eur J Vasc Endovasc Surg 1999; 18: 445-449
    CrossrefGoogle Scholar
  • 38 Holt PJ, Poloniecki JD, Khalid U et al. Effect of endovascular aneurysm repair on the volume-outcome relationship in aneurysm repair. Circ Cardiovasc Qual Outcomes 2009; 2: 624-632
    CrossrefGoogle Scholar
  • 39 Armon MP, Wenham PW, Whitaker SC et al. Common iliac artery aneurysms in patients with abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 1998; 15: 255-257
    CrossrefGoogle Scholar
  • 40 Bastos Gonçalves F, Baderkhan H, Verhagen HJ et al. Early sac shrinkage predicts a low risk of late complications after endovascular aortic aneurysm repair. Br J Surg 2014; 101: 802-810
    CrossrefGoogle Scholar
  • 41 Heikkinen M, Salenius JP, Auvinen O. Ruptured abdominal aortic aneurysm in a well-defined geographic area. J Vasc Surg 2002; 36: 291-296
    CrossrefGoogle Scholar
  • 42 Trenner M, Haller B, Söllner H et al. 12 Jahre „Qualitätssicherung BAA“ der DGG, Teil II. Gefässchirurgie 2013; 18: 372-380
    CrossrefGoogle Scholar
  • 43 Karthikesalingam A, Holt PJ, Vidal-Diez A et al. Mortality from ruptured abdominal aortic aneurysms: clinical lessons from a comparison of outcomes in England and the USA. Lancet 2014; 383: 963-969
    CrossrefGoogle Scholar
  • 44 Sakalihasan N, Limet R, Defawe OD. Abdominal aortic aneurysm. Lancet 2005; 365: 1577-1589
    CrossrefGoogle Scholar
  • 45 Marston WA, Ahlquist R, Johnson Jr G et al. Misdiagnosis of ruptured abdominal aortic aneurysms. J Vasc Surg 1992; 16: 17-22
    CrossrefGoogle Scholar
  • 46 Lloyd GM, Bown MJ, Norwood MG et al. Feasibility of preoperative computer tomography in patients with ruptured abdominal aortic aneurysm: a time-to-death study in patients without operation. J Vasc Surg 2004; 39: 788-791
    CrossrefGoogle Scholar
  • 47 Mastracci TM, Garrido-Olivares L, Cinà CS et al. Endovascular repair of ruptured abdominal aortic aneurysms: a systematic review and meta-analysis. J Vasc Surg 2008; 47: 214-221
    CrossrefGoogle Scholar
  • 48 Bickell WH, Wall Jr MJ, Pepe PE et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331: 1105-1109
    CrossrefGoogle Scholar
  • 49 Karkos CD, Menexes GC, Patelis N et al. A systematic review and meta-analysis of abdominal compartment syndrome after endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2014; 59: 829-842
    CrossrefGoogle Scholar
  • 50 Kazmers A, Perkins AJ, Jacobs LA. Aneurysm rupture is independently associated with increased late mortality in those surviving abdominal aortic aneurysm repair. J Surg Res 2001; 95: 50-53
    CrossrefGoogle Scholar
  • 51 O’Donnell ME, Badger SA, Makar RR et al. Techniques in occluding the aorta during endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg 2006; 44: 211-215
    CrossrefGoogle Scholar
  • 52 Rayt HS, Bown MJ, Lambert KV et al. Buttock claudication and erectile dysfunction after internal iliac artery embolization in patients prior to endovascular aortic aneurysm repair. Cardiovasc Intervent Radiol 2008; 31: 728-734
    CrossrefPubMedGoogle Scholar
  • 53 Flanigan DP, Schuler JJ, Keifer T et al. Elimination of iatrogenic impotence and improvement of sexual function after aortoiliac revascularization. Arch Surg 1982; 117: 544-550
    CrossrefGoogle Scholar
  • 54 Weinstein MH, Machleder HI. Sexual function after aorto-lliac surgery. Ann Surg 1975; 181: 787-790
    CrossrefGoogle Scholar
  • 55 Lederle FA, Johnson GR, Wilson SE et al. Quality of life, impotence, and activity level in a randomized trial of immediate repair versus surveillance of small abdominal aortic aneurysm. J Vasc Surg 2003; 38: 745-752
    CrossrefGoogle Scholar
  • 56 Berg P, Kaufmann D, van Marrewijk CJ et al. Spinal cord ischaemia after stent-graft treatment for infra-renal abdominal aortic aneurysms. Analysis of the Eurostar database. Eur J Vasc Endovasc Surg 2001; 22: 342-347
    CrossrefPubMedGoogle Scholar
  • 57 Bjorck M, Bergqvist D, Troeng T. Incidence and clinical presentation of bowel ischaemia after aortoiliac surgery – 2930 operations from a population-based registry in Sweden. Eur J Vasc Endovasc Surg 1996; 12: 139-144
    CrossrefGoogle Scholar
  • 58 Longo WE, Lee TC, Barnett MG et al. Ischemic colitis complicating abdominal aortic aneurysm surgery in the U.S. veteran. J Surg Res 1996; 60: 351-354
    CrossrefGoogle Scholar
  • 59 Seeger JM, Coe DA, Kaelin LD et al. Routine reimplantation of patent inferior mesenteric arteries limits colon infarction after aortic reconstruction. J Vasc Surg 1992; 15: 635-641
    CrossrefGoogle Scholar
  • 60 Debus ES, Diener H, Larena-Avellaneda A. Akute intestinale Ischämie. Gefässchirurgie 2010; 15: 61-72
    CrossrefGoogle Scholar
  • 61 Perry RJ, Martin MJ, Eckert MJ et al. Colonic ischemia complicating open vs endovascular abdominal aortic aneurysm repair. J Vasc Surg 2008; 48: 272-277
    CrossrefGoogle Scholar
  • 62 Gleeson TG, Bulugahapitiya S. Contrast-induced nephropathy. AJR Am J Roentgenol 2004; 183: 1673-1689
    CrossrefGoogle Scholar
  • 63 Greenberg RK, Chuter TA, Lawrence-Brown M et al. Analysis of renal function after aneurysm repair with a device using suprarenal fixation (Zenith AAA Endovascular Graft) in contrast to open surgical repair. J Vasc Surg 2004; 39: 1219-1228
    CrossrefGoogle Scholar
  • 64 AbuRahma AF, Campbell J, Stone PA et al. The correlation of aortic neck length to early and late outcomes in endovascular aneurysm repair patients. J Vasc Surg 2009; 50: 738-748
    CrossrefGoogle Scholar
  • 65 Schlösser FJ, Gusberg RJ, Dardik A et al. Aneurysm rupture after EVAR: Can the ultimate failure be predicted?. Eur J Vasc Endovasc Surg 2009; 37: 15-22
    CrossrefPubMedGoogle Scholar