Management von Viszeralarterienaneurysmen unter besonderer Berücksichtigung der Organperfusion – Erfahrungen über mehr als 20 Jahre

Zusammenfassung

Einleitung Viszeralarterienaneurysmen (VAA) sind selten und werden meist als Zufallsbefund entdeckt. Die Indikation zur Behandlung besteht bei symptomatischen Patienten, Pseudoaneurysmen sowie bei asymptomatischen Patienten bei einer Größe von mehr als 2,5 cm (Viszeralarterienaneurysmen) bzw. mehr als 3 cm (Nierenarterienaneurysmen), bei Schwangeren und vor einer Lebertransplantation. Neben der erfolgreichen, operativen oder endovaskulären Ausschaltung des Aneurysmas ist der Erhalt der Organperfusion wichtig. Die folgende Arbeit stellt das Management von Viszeralarterienaneurysmen und die Erfahrungen über einen Zeitraum von mehr als 20 Jahren dar und zeigt einen Behandlungsalgorithmus auf.

Patienten Zwischen 1995 und 2018 wurden am Universitätsklinikum Regensburg 179 VAA diagnostiziert (84 Männer, 95 Frauen, medianes Alter 62 (18 – 87) Jahre). 113-mal (63%) lag ein Milzarterien-, 21- bzw. 22-mal (je 12%) ein Nieren- und Leberarterienaneurysma vor. 14-mal (8%) fand sich ein Aneurysma der gastropankreatikoduodenalen Arkade, 9-mal (5%) der A. mesenterica superior/inferior. 110 (62%) Patienten wurden bei fehlender Behandlungsindikation nachbeobachtet, 34 (19%) offen und 35 (19%) endovaskulär behandelt. Bei allen wurde präoperativ eine Bildgebung, meist mit CT-Angiografie durchgeführt.

Ergebnisse Von den 69 therapierten Patienten mit VAA wurden 51 (74%) elektiv und 18 (26%) notfallmäßig wegen Blutung behandelt. 16 Notfallpatienten wurden endovaskulär, 2 offen chirurgisch behandelt. Postoperativ fand sich 2-mal eine partielle Minderdurchblutung der Leber, die folgenlos blieb. Einmal musste Dünndarm teilreseziert werden. 32/51 (63%) elektive VAA wurden offen, 19/51 (37%) endovaskulär therapiert. Leber und Darm blieben bei beiden Verfahren intakt. Bei den 21 Milz- und Nierenarterienaneurysmen wurde operativ 4-mal die Milz, 1-mal die Niere komplett entfernt, zusätzlich fanden sich postoperativ 3 Nierenteilinfarkte (gesamt 8/21 [38%]). Postinterventionell zeigte sich bei den 14 Milz- und Nierenarterienaneurysmen 2-mal ein Milz- und 3-mal ein Nierenteilinfarkt, 2-mal wurde die Milz später entfernt (gesamt 7/14 [50%]). Zum Nachweis der Organperfusion wurde die CT-Angiografie, vor allem aber der Kontrastmittelultraschall (CEUS) durchgeführt.

Schlussfolgerung Bei Blutung und Pseudoaneurysmen ist die endovaskuläre Therapie das Vorgehen der ersten Wahl. Bei elektiven Eingriffen spielt die sorgfältige Planung im Hinblick auf die technische Machbarkeit der Aneurysmaausschaltung, aber auch der Erhalt der Organperfusion, vor allem bei Milz- und Nierenarterienaneurysmen, eine entscheidende Rolle. Eine bildgebende Nachsorge, vorzugsweise mit Ultraschall, wird dringend empfohlen. Vor bzw. nach Splenektomie oder bei funktioneller Asplenie sind entsprechende Impfungen vorgeschrieben.

Abstract

Background Visceral artery aneurysms (VAA) are rare and often incidental findings. Indications for treatment are symptomatic patients, pseudoaneurysms and a true aneurysm of diameter of ≥ 2.5 cm for mesenteric arteries and ≥ 3 cm for renal artery aneurysms. Pregnancy and liver transplantation play an important role in aneurysm rupture. Technical success after open or endovascular procedure and maintenance of organ perfusion are crucial. The aim of this review is to evaluate our data and experience of more than 20 years and to develop a strategy to deal with visceral artery aneurysm in elective and emergency cases.

Patients Between 1995 and 2018, 179 patients (84 males, 95 females, median age 62 [18 – 87] years) were diagnosed with VAA at the Regensburg University Hospital. The site of aneurysm was the splenic artery in 113 (63%) patients (pts), hepatic and renal arteries in 22 and 21 pts (12% each), and gastropancreaticoduodenal artery in 14 (8%) and superior/inferior mesenteric artery in 9 (5%) cases. Surveillance without intervention occurred in 110 (62%) pts, and 34 (19%) pts underwent open and 35 (19%) endovascular repair. In all patients, preoperative imaging was performed, preferably by computed tomography angiography (CTA).

Results A total of 69 patients underwent open or endovascular repair. 51 (74%) pts were treated electively, 18 (26%) pts presented urgently with acute bleeding. 16 emergency pts received endovascular treatment, and in 2 pts open surgery was performed. After emergency treatment, two pts exhibited segmental liver malperfusion without consequences. In one case, segmental bowel resection was necessary. 32/51 (63%) patients were treated electively by open surgery, 19/51 (37%) by endovascular procedures. There were no liver or bowel infarctions. Four splenectomies and one unilateral nephrectomy were necessary in patients with splenic or renal artery aneurysms. Moreover, three partial renal infarctions were noticed postoperatively (overall 8/21 [38%]). After endovascular repair of splenic or renal artery aneurysms, two cases of splenic and three cases of renal segmental infarction were observed. Splenectomy had to be performed twice (overall 7/14 [50%]). Organ perfusion was monitored by CTA, and preferentially by contrast enhanced ultrasound.

Conclusion The endovascular approach is the preferred option in an emergency to control bleeding in pseudoaneurysms. Patients for elective splenic or renal artery aneurysm repair have to be evaluated very carefully to achieve technical success with occlusion of the aneurysm and excellent organ perfusion. Imaging techniques such as ultrasound, especially CEUS, are strongly recommended in postoperative follow-up. Partial or complete splenic infarction leads to vaccination.

Schlüsselwörter

Viszeralarterienaneurysma - endovaskuläre Behandlung - offene Operation - Organperfusion - Kontrastmittelultraschall

Key words

visceral artery aneurysm - endovascular treatment - open repair - organ perfusion - contrast enhanced ultrasound

• Literatur

• 1 van Rijn MJ, Ten Raa S, Hendriks JM. et al. Visceral aneurysms: Old paradigms, new insights?. Best Pract Res Clin Gastroenterol 2017; 31: 97-104
• 2 Bjorck M, Koelemay M, Acosta S. et al. Editorʼs Choice – Management of the Diseases of Mesenteric Arteries and Veins: Clinical Practice Guidelines of the European Society of Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2017; 53: 460-510
• 3 Meyer A, Lang W. [Visceral artery aneurysms]. Gefässchirurgie 2011; 16: 355-362
• 4 Hogendoorn W, Lavida A, Hunink MG. et al. Open repair, endovascular repair, and conservative management of true splenic artery aneurysms. J Vasc Surg 2014; 60: 1667-1676 e1661
• 5 Juntermanns B, Bernheim J, Karaindros K. et al. Visceral artery aneurysms. Gefässchirurgie 2018; 23: 19-22
• 6 Litt B, Mussari B, Gauvin G. et al. Visceral artery aneurysms: an atypical presentation of large-vessel vasculitis. CMAJ 2017; 189: E464-E467
• 7 Kunz WG, Paprottka PM, Reichelt A. Segmentale Arterielle Mediolyse (SAM) – Eine seltene Differenzialdiagnose multipler Viszeralaneurysmen. Rofo 2016; 188: 687-689
• 8 Abdelgabar A, dʼArchambeau O, Maes J. et al. Visceral artery pseudoaneurysms: two case reports and a review of the literature. J Med Case Rep 2017; 11: 126
• 9 Guo B, Guo D, Xu X. et al. Early and intermediate results of endovascular treatment of symptomatic and asymptomatic visceral artery aneurysms. J Vasc Surg 2016; 64: 140-148
• 10 Pulli R, Dorigo W, Troisi N. et al. Surgical treatment of visceral artery aneurysms: a 25-year experience. J Vasc Surg 2008; 48: 334-342
• 11 Klausner JQ, Lawrence PF, Harlander-Locke MP. et al. The contemporary management of renal artery aneurysms. J Vasc Surg 2015; 61: 978-984
• 12 Marone EM, Mascia D, Kahlberg A. et al. Is open repair still the gold standard in visceral artery aneurysm management?. Ann Vasc Surg 2011; 25: 936-946 doi:10.1016/j.avsg.2011.03.006
• 13 Piffaretti G, Lomazzi C, Carrafiello G. et al. Visceral artery aneurysms: management of 48 cases. J Cardiovasc Surg (Torino) 2011; 52: 557-565
• 14 Batagini NC, El-Arousy H, Clair DG. et al. Open versus endovascular treatment of visceral artery aneurysms and pseudoaneurysms. Ann Vasc Surg 2016; 35: 1-8
• 15 Hemp JH, Sabri SS. Endovascular management of visceral arterial aneurysms. Tech Vasc Interv Radiol 2015; 18: 14-23
• 16 Regus S, Lang W. Rupture risk and etiology of visceral artery aneurysms and pseudoaneurysms: a single-center experience. Vasc Endovascular Surg 2016; 50: 10-15
• 17 Tulsyan N, Kashyap VS, Greenberg RK. et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007; 45: 276-283
• 18 Ferrero E, Ferri M, Viazzo A. et al. Visceral artery aneurysms, an experience on 32 cases in a single center: treatment from surgery to multilayer stent. Ann Vasc Surg 2011; 25: 923-935
• 19 Dorigo W, Pulli R, Azas L. et al. Early and intermediate results of elective endovascular treatment of true visceral artery aneurysms. Ann Vasc Surg 2016; 30: 211-218
• 20 Ruffino M, Rabbia C. Italian Cardiatis Registry Investiagtors Group. Endovascular treatment of visceral artery aneurysms with Cardiatis multilayer flow modulator: preliminary results at six-month follow-up. J Cardiovasc Surg (Torino) 2011; 52: 311-321
• 21 Colombi D, Bodini FC, Bossalini M. et al. Extracranial visceral artery aneurysms/pseudoaneurysms repaired with flow diverter device developed for cerebral aneurysms: preliminary results. Ann Vasc Surg 2018;
• 22 Anton S, Stahlberg E, Horn M. et al. Initial experience with the E-ventus^® stent-graft for endovascular treatment of visceral artery aneurysms. J Cardiovasc Surg (Torino) 2018; 59: 225-231
• 23 Venturini M, Marra P, Colombo M. et al. Endovascular treatment of visceral artery aneurysms and pseudoaneurysms in 100 patients: covered stenting vs. transcatheter embolization. J Endovasc Ther 2017; 24: 709-717
• 24 Cappucci M, Zarco F, Orgera G. et al. Endovascular treatment of visceral artery aneurysms and pseudoaneurysms with stent-graft: Analysis of immediate and long-term results. Cir Esp 2017; 95: 283-292
• 25 Landwehr P, Arnold S, Voshage G. et al. [Embolotherapy: principles and indications]. Gefässchirurgie 2008; 13: 437-461
• 26 Ruhnke H, Kröncke TJ. Aneurysmen und Pseudoaneurysmen viszeraler Arterien – interventionelle Therapie. Gefäßmedizin Scan 2018; 5: 63-75
• 27 Ikeda O, Tamura Y, Nakasone Y. et al. Nonoperative management of unruptured visceral artery aneurysms: treatment by transcatheter coil embolization. J Vasc Surg 2008; 47: 1212-1219
• 28 Etezadi V, Gandhi RT, Benenati JF. et al. Endovascular treatment of visceral and renal artery aneurysms. J Vasc Interv Radiol 2011; 22: 1246-1253
• 29 Pfister K, Kasprzak PM, Jung EM. et al. Contrast-enhanced ultrasound to evaluate organ microvascularization after operative versus endovascular treatment of visceral artery aneurysms. Clin Hemorheol Microcirc 2016; 64: 689-698
• 30 Scholtz V, Meyer F, Udelnow A. et al. [Differential vascular medical management of visceral artery aneurysms in a single-centre consecutive patient cohort as part of an ongoing disease-specific systematic clinical prospective observational study]. Zentralbl Chir 2014; 140: 478-485
• 31 Song C, Dong J, Yu G. et al. Comparison of open surgery and endovascular procedures as a therapeutic choice for visceral artery aneurysms. Vascular 2018; 26: 387-392
• 32 Chin JA, Heib A, Ochoa Chaar CI. et al. Trends and outcomes in endovascular and open surgical treatment of visceral aneurysms. J Vasc Surg 2017; 66: 195-201.e1
• 33 Acosta S, Asciutto G. Endovascular therapy for visceral artery aneurysms. Int Angiol 2016; 35: 573-578
• 34 Shibata E, Takao H, Amemiya S. et al. 3D-printed visceral aneurysm models based on CT data for simulations of endovascular embolization: evaluation of size and shape accuracy. AJR Am J Roentgenol 2017; 209: 243-247
• 35 Duran M, Hausmann DF, Grabitz K. et al. Reconstruction for renal artery aneurysms using the tailoring technique. J Vasc Surg 2017; 65: 438-443
• 36 Regus S, Lang W. Management of true visceral artery aneurysms in 31 cases. J Visc Surg 2016; 153: 347-352
• 37 Balderi A, Antonietti A, Ferro L. et al. Endovascular treatment of visceral artery aneurysms and pseudoaneurysms: our experience. Radiol Med 2012; 117: 815-830
• 38 Kok HK, Asadi H, Sheehan M. et al. Systematic review and single-center experience for endovascular management of visceral and renal artery aneurysms. J Vasc Interv Radiol 2016; 27: 1630-1641
• 39 Kunzle S, Glenck M, Puippe G. et al. Stent-graft repairs of visceral and renal artery aneurysms are effective and result in long-term patency. J Vasc Interv Radiol 2013; 24: 989-996
• 40 Klausner JQ, Harlander-Locke MP, Plotnik AN. et al. Current treatment of renal artery aneurysms may be too aggressive. J Vasc Surg 2014; 59: 1356-1361
• 41 Buck DB, Curran T, McCallum JC. et al. Management and outcomes of isolated renal artery aneurysms in the endovascular era. J Vasc Surg 2016; 63: 77-81
• 42 Spiliopoulos S, Sabharwal T, Karnabatidis D. et al. Endovascular treatment of visceral aneurysms and pseudoaneurysms: long-term outcomes from a multicenter European study. Cardiovasc Intervent Radiol 2012; 35: 1315-1325
• 43 Tsilimparis N, Reeves JG, Dayama A. et al. Endovascular vs. open repair of renal artery aneurysms: outcomes of repair and long-term renal function. J Am Coll Surg 2013; 217: 263-269
• 44 Katsura M, Sato J, Akahane M. et al. Single-energy metal artifact reduction technique for reducing metallic coil artifacts on post-interventional cerebral CT and CT angiography. Neuroradiology 2018;
• 45 Schierling W, Goecze I, Apfelbeck H. et al. [„Bedside“-Ultrasound after aortic surgery]. Gefässchirurgie 2018 [German; accepted].
• 46 Di Sabatino A, Lenti MV, Tinozzi FP. et al. Vaccination coverage and mortality after splenectomy: results from an Italian single-centre study. Intern Emerg Med 2017; 12: 1139-1147