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Zentralbl Chir 2014; 139(S 02): e97-e102
DOI: 10.1055/s-0032-1328177
Originalarbeit
Georg Thieme Verlag KG Stuttgart · New York

Routinemäßige Subclavia-Revaskularisation in Regionalanästhesie

Routine Subclavian Revascularisation Employing Regional Anaesthesia
N. H. Clausen
1   Klinik für Gefäß- und Endovascularchirurgie, Klinikum der J. W. Goethe-Universität Frankfurt am Main, Deutschland
,
C. Byhahn
2   Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Klinikum der J. W. Goethe-Universität Frankfurt am Main, Deutschland
,
T. Schmitz-Rixen
1   Klinik für Gefäß- und Endovascularchirurgie, Klinikum der J. W. Goethe-Universität Frankfurt am Main, Deutschland
,
K. Zacharowski
2   Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Klinikum der J. W. Goethe-Universität Frankfurt am Main, Deutschland
,
T. C. Schmandra
1   Klinik für Gefäß- und Endovascularchirurgie, Klinikum der J. W. Goethe-Universität Frankfurt am Main, Deutschland
› Author Affiliations
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Publication History

Publication Date:
25 April 2013 (online)

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Zusammenfassung

Einleitung: Die Subclavia-Carotis-Transposition (SCT) gewinnt im Zeitalter der elektiven wie notfallmäßigen endovaskulären Chirurgie an der thorakalen Aorta (TEVAR) zunehmend an Bedeutung. Durch die Inkaufnahme der Überstentung des Abgangs der linken A. subclavia lässt sich zusätzliche proximale Landungszone gewinnen. Führt dies zu einem Subclavian-Steal-Syndrom, einer vertebrobasilären Insuffizienz, einem Endoleak II oder bestehen Prädiktoren für eine spinale Ischämie, kann die SCT sicher und schonend in Regionalanästhesie mittels Zervikalblock durchgeführt werden. Material und Methoden: Seit Januar 2010 wurde in unserer Klinik eine konsekutive Serie von 13 Patienten routinemäßig in Regionalanästhesie operiert. Die Operationsindikation ergab sich in Zusammenhang mit einer geplanten oder bereits erfolgten Aortenstentintervention bei Aneurysmaerkrankung bzw. Dissektion. Hinzu kam ein Patientenkollektiv mit (prä-)okklusiver arterieller Verschlusskrankheit des Aortenbogens. Der peri- und postoperative klinische Verlauf wurde im Sinne einer prospektiven Beobachtungsstudie erfasst. Ergebnisse: Wir führten in 62 % der Fälle (n = 8) eine Transposition der A. subclavia auf die A. carotis communis durch. In 38 % der Fälle (n = 5) wurde intraoperativ die Anlage eines karotidosubklavialen Bypasses präferiert. Die technische Erfolgsquote der jeweiligen Rekonstruktion lag bei 100 %. Die Konversion auf eine Intubationsnarkose war in 30 % der Fälle (n = 4) erforderlich. Im Follow-up zeigen sich alle Rekonstruktionen durchgängig. Schlussfolgerung: Die Revaskularisation der linken A. subclavia durch Subclavia-Carotis-Transposition oder karotidosubklaviale Bypassanlage ist ein technisch gut realisierbarer und sicherer Eingriff nach endovaskulärer Überstentung der A. subclavia. Die Realisierung der Operation ist am normal dimensionierten Patienten in Regionalanästhesie – ähnlich wie in der Carotischirurgie – gut durchführbar. Somit kann dieser Eingriff auch Risikopatienten angeboten werden.

Abstract

Introduction: The increasing incidence of endovascular surgery on the thoracic aorta (TEVAR) is leading to an increased rate of subclavian-carotid transposition (SCT). Intentional overstenting of the left subclavian artery extends the proximal landing zone. If overstenting leads to a subclavian steal syndrome, vertebrobasilar insufficiency or if the risk of spinal ischaemia is present, SCT can safely be carried out with regional anaesthesia by means of a cervical block. Materials and Methods: Since January 2010 regional anaesthesia was employed in 13 consecutive patients receiving an SCT in our clinic. Subclavian revascularisation was performed either as adjunct procedure for TEVAR or in patients with occlusive disease of the aortic arch. The clinical course was prospectively observed. Results: In 62 % of the cases (n = 8) a transposition of the subclavian artery onto the common carotid artery was carried out. In 38 % of the cases (n = 5) an intraoperative decision was made to construct a carotid-subclavian bypass. In 30 % (n = 4) of the cases a conversion from cervical block to general anaesthesia was necessary. All reconstructions proved to be patent at follow-up. Conclusion: Subclavian-carotid transposition under regional anaesthesia is safe and technically feasible if occlusion of the subclavian artery by thoracic stentgraft or stenosis has occurred. The technique employing regional anaesthesia can, therefore, also be offered to patients with increased risk for complications due to general anaesthesia.

Schlüsselwörter

thorakaler Endostent - Aortenaneurysma - endovaskuläre Therapie - Regionalanästhesie - Zervikalblock

Key words

thoracic endostent - aortic aneurysm - endovascular treatment - regional anaesthesia - cervical block
 

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