Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?

Zusammenfassung

Der offen-chirurgische thorakale und thorakoabdominelle Aortenersatz (open repair, OR) bei Aneurysmen oder Dissektionen hat in der aktuellen Versorgungsrealität im Vergleich zur endovaskulären Versorgung mit einfachen und speziellen Stentprothesen (fenestrated/branched [thoracic] endovascular aortic repair, f/b[T]EVAR) eine deutlich untergeordnete Rolle. Zudem besteht die Notwendigkeit einer hohen technischen Expertise und eines umfangreichen operativen Settings, um ein OR sicher anbieten zu können.

Zu Reduktion der spezifischen Komplikationen, wie z. B. perioperative Mortalität, permanente Dialysepflichtigkeit, spinale Ischämie, Schlaganfall oder Mesenterialischämie, ist ein hohes Maß an intraoperativer Protektion, z. B. mittels Liquordrainage, Point-of-Care-Gerinnungstherapie, distaler oder selektiver Aortenperfusion im Sinne eines temporären Linksherzbypasses und sequenziellem Clamping der Aorta erforderlich. Trotz der Dominanz der endovaskulären Therapie ist diese Expertise aber weiterhin nötig, um spezifische Indikationen, wie beispielsweise junges Patientenalter oder Bindegewebserkrankungen bzw. Protheseninfektionen, sicher versorgen zu können. Zusätzlich ist nicht jedes Aneurysma oder jede Dissektion anatomisch langfristig sicher mit einer endovaskulären Behandlung zu therapieren.

Die aktuelle Evidenzlage sieht einen geringen, meist nicht statistisch signifikanten Vorteil von TEVAR und f/bEVAR versus OR bei den wichtigsten kurz- und mittelfristigen Ergebnisparametern, bei deutlich geringerer Invasivität und verkürzter Krankenhausliegedauer. Im langfristigen Verlauf sind die Ergebnisse bezüglich Gesamtüberleben und Re-Interventionsraten bzw. sekundärer Komplikationen bei OR deutlich besser.

Der offene thorakoabdominelle Aortenersatz ist also nach wie vor mehr als ein exklusives Hobby, sondern vielmehr eine absolute Notwendigkeit im Gesamtspektrum der aortalen Chirurgie, dessen Bedeutung in den nächsten Jahren mutmaßlich wieder zunimmt.

Abstract

The classical approach of open repair (OR) for thoracic and thoracoabdominal aortic pathologies, including aneurysms and dissection, has been outnumbered by the use of fenestrated/branched (thoracic) endovascular aortic repair (f/b[T]EVAR) in recent years. Providing OR for complex cases in an aortic service requires a dedicated surgical setup and a huge body of expertise in this particular field.

In order to reduce specific complications, such as perioperative mortality, kidney failure, spinal cord ischemia, stroke or bowel ischemia, it is necessary to apply cerebrospinal-spinal fluid drainage, point-of-care coagulation therapy, distal and retrograde aortic perfusion and sequential clamping. Despite the predominance of endovascular solutions, the specific OR expertise is still needed for specific indications, such as young patients, connective tissue disorder or aortic graft infections.

Currently, the short and mid term results for f/b(T)EVAR outweigh those for OR, including the shorter hospital stay and less invasive procedures. However, OR provides better long-term results for overall mortality, re-intervention rates and secondary complications.

In conclusion, in our opinion OR is a service that is still necessary for dedicated aortic centres, but will most likely become more frequent again in the years to come.

Schlüsselwörter

Aortenaneurysma - open repair - thorako-abdominale Aorta - Bindegewebserkrankung - spinale Ischämie

Keywords

aortic aneurysm - open repair - thoracoabdominal aorta - connective tissue disease - spinal cord ischemia

Publication History

Received: 11 June 2021

Accepted after revision: 28 July 2021

Article published online:
19 October 2021

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