Paraplegie nach endovaskulärer Therapie der thorakalen und thorakoabdominellen Aorta

Zusammenfassung

Ziel: Ziel dieser Arbeit war es, die Inzidenz und Ätiologie der postoperativen Paraplegie nach endovaskulärer Chirurgie thorakaler und thorakoabdomineller Aortenpathologien zu analysieren. Methodik: Diese retrospektive Monozenterstudie umfasst 173 Patienten (131 Männer, Durchschnittsalter: 62 J.), die zwischen März 1997 und April 2007 in unserer Klinik wegen folgender Pathologien der thorakoabdominellen Aorta endovaskulär therapiert wurden: 36 thorakale Aortenaneurysmen (TAA), 33 thorakoabdominelle Aortenaneurysmen (TAAA), 43 Aortendissektionen Stanford Typ B und 5 Typ A, 31 penetrierende aortale Ulzera, 9 traumatische Aortenrupturen, 5 posttraumatische TAA, 8 aortobronchiale Fisteln und 3 falsche Aneurysmen. 101 Patienten (58 %) wurden notfallmäßig operiert, die restlichen 72 elektiv. Die Auswahl kommerziell hergestellter Endoprothesen und Planung erfolgten anhand der präoperativen CT-Angiografie. Das Follow-up beinhaltete eine Röntgen-Thorax-Aufnahme in 3 Ebenen und eine CT-Angiografie vor Entlassung, 6 und 12 Monate postoperativ, danach jährlich. Ergebnisse: Die primäre technische Erfolgsrate betrug 98 % (170 von 173), die 30-Tage-Mortalität 9,2 %. Die mittlere Nachbeobachtungszeit betrug 52 Monate (Spannbreite 1–96 Monate). Eine postoperative Paraparese oder Paraplegie trat bei 3 Patienten auf (1,7 %). Diese 3 Patienten erhielten eine Kombination offener und endovaskulärer Rekonstruktionsverfahren bei sehr ausgedehnten thorakoabdominellen Aneurysmen in 2 Fällen und einer chronisch expandierenden Aortendissektion im dritten Fall. Schlussfolgerungen: Die endovaskuläre Therapie der thorakalen und thorakoabdominellen Aorta trägt ein geringes Risiko für eine postoperative Paraplegie. Patienten mit langstreckigen Pathologien und aortalen Voroperationen sind besonders gefährdet.

Abstract

Aim: The aim of this study was to analyse the incidence and aetiology of paraplegia secondary to endovascular repair of the thoracic and thoracoabdominal aorta (TEVAR). Methods: A retrospective study was conducted in the patients treated at our facility between March 1997 and April 2007. During this interval, 173 patients (163 men; median age: 62 years) underwent endovascular repair of the thoracic aorta. Indications for treatment were thoracic aortic aneurysms in 36 patients, thoracoabdominal aortic aneurysms in 33 patients, type B dissections in 43 patients, type A dissections in 5 patients, penetrating aortic ulcers in 31 patients, traumatic aortic transections in 9 patients, post-traumatic aortic aneurysms in 5 patients, aortobronchial fistulas in 8 patients, aortic patch ruptures in 2 patients, and an anastomotic aortic aneurysm in 1 patient. 101 procedures (58 %) were conducted as emergency interventions while 72 were elective. Device design and implant strategy were chosen on the basis of an evaluation of morphology from a computed tomographic scan. Clinical assessment and imaging of the aorta (CT or magnetic resonance imaging) during follow up were performed prior to discharge, at 6 and 12 months, and then annually. Results: A primary technical success was achieved in 170 patients (98 %). The overall 30-day mortality rate was 9.2 %. Length of follow-up ranged from 1 to 96 months, with a mean of 52 months. Paraplegia or paraparesis developed in 3 patients (1.7 %). Two of these patients had a thoracoabdominal aortic aneurysm and the third a chronic expanding type B dissection, being treated with hybrid procedures. Conclusions: Endovascular repair of the thoracic and thoracoabdominal aorta is associated with a relatively low risk for postoperative paraplegia or paraparesis. Patients requiring long segment aortic coverage, and with prior aortic replacement are especially at risk.

Paraplegie - spinale Ischämie - thorakale Aorta - endovaskulär - Endoprothese

paraplegia - spinal cord ischaemia - thoracic aorta - endovascular - stent-graft

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