Abdominale und thorakale Aortenaneurysmen – Endovaskuläre und offene Therapie

Bei der Indikationsstellung zur offenen oder endovaskulären Therapie einer aneuysmatischen Aortenerkrankung oder Aortendissektion sind das Rupturrisiko, individuelle Lebenserwartung, Co-Morbiditäten, die eingriffsbedingte Komplikationsrate und der Patientenwunsch zu berücksichtigen.

Aufgrund guter primärer und mittelfristiger Behandlungsergebnisse besitzt die endovaskuläre Therapie neben der konventionell-offenen Operation mittlerweile einen festen Platz bei der elektiven und notfallmäßigen Versorgung. Unter sorgfältiger Abwägung von Behandlungsindikation, individueller Aneurysmamorphologie und patientenspezifischer Einfluss- und Risikofaktoren lassen sich in gefäßchirurgischen Zentren > 2/3 aller abdominellen Aortenaneurysmen (AAA) mit guten frühen und mittelfristigen Ergebnissen mittels endovaskulärer Therapie (EVAR) behandeln. Wegen der häufigeren methodenspezifischen Sekundär- bzw. Spätkomplikationen sind besonders nach endovaskulärer Therapie konsequente Nachkontrollen unerlässlich. Trotz signifikanter Reduktion der perioperativen Letalität und Morbidität sollte sich die Indikationsstellung zur endovaskulären Therapie weiterhin an den derzeit etablierten und klinisch üblichen Kriterien für die konventionell-offene Aneurysmachirurgie orientieren. Bei der Behandlung von rupturierten AAA gewinnt die notfallmäßige endovaskuläre Versorgung (eEVAR) immer mehr an Bedeutung. Tendenziell kann dabei durch eEVAR an Zentren mit entsprechender endovaskulärer Erfahrung und Patientenselektion eine wesentliche Reduktion der rupturbedingten Mortalität von ca. 40–60 % auf etwa 20 % erzielt werden. Größere prospektiv randomisierte Studien müssen dies jedoch noch bestätigen sowie diejenigen Patientengruppen identifizieren, die besonders von eEVAR profitieren.

The indication to treat an aortic aneurysm or artic dissection by open or endovascular means is influenced by clinical signs, diameter, growth rate, individual life expectancy, morphology, co-morbidities, risk of the procedure and patient's preference. Due to good primary and mid-term outcomes, endovascular aortic repair (EVAR) is now accepted as an additional standard procedure in elective and emergency situations. In aortic centers meanwhile more than 2/3 of all patients with aortic aneurysms or dissections are treated by EVAR. Since additional procedures are necessary in about 10 % of these patients long-term surveillance is mandatory.

Key words

Aortic aneurysm - aortic dissection - endovascular therapy - open repair

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