Debatte infrarenales AAA bei jüngeren Patienten („fit for open repair“): Der offene Aortenersatz ist sicher und hat ein besseres Langzeitergebnis

Zusammenfassung

Die endovaskuläre Aneurysmatherapie, initial als Behandlungsverfahren für diejenigen Patienten eingeführt, die ein prohibitives Risiko für den offenen Aortenersatz vorwiesen, hat sich nach technischer Evolution zu einer sicheren und letztendlich präferierten Behandlungsmodalität des Bauchaortenaneurysmas für alle Patienten entwickelt. Die Spätanalysen der prospektiv-randomisierten Studien zur endovaskulären Behandlung belegen allerdings eine eingeschränkte Ergebnisqualität gegenüber der offenen Operation durch erhöhte Sterblichkeit und Reinterventionsrate im Langzeitverlauf (8 Jahre). Die offen-chirurgische Behandlung des infrarenalen Bauchaortenaneurysmas kann eine Erfahrung im klinischen Einsatz von 7 Dekaden vorweisen und erzielt gerade bei jüngeren Patienten mit niedrigem operativem Risiko exzellente Ergebnisse. Faktoren wie Narbenbrüche, erektile Dysfunktion oder reduzierte Lebensqualität, die meist als spezifischer Nachteil der offenen Operation angeführt werden, können wirksam verhindert werden (Netzimplantation) bzw. zeigen in neueren Metaanalysen keinen Unterschied zur endovaskulären Therapie. Der individuellen Beurteilung des Patienten sowie seines operativen Risikos anhand validierter Parameter kommt damit eine zentrale Bedeutung in der Weichenstellung zwischen den beiden Behandlungsverfahren zu, die im Falle von niedrigem Alter und Komorbiditätsprofil, großem Aneurysma sowie ggf. vorhandener atoper Nierenarterien bzw. dominanter A. mesenterica inferior eine Empfehlung für die offene Operation favorisieren sollte.

Abstract

Endovascular aortic repair, initially developed for patients at prohibitively high risk for an open repair, has undergone significant technical evolution and refinement and has emerged as the preferred treatment option for patients with an infrarenal aortic aneurysm. However, analysis of long-term data of the randomised studies revealed inferior results with regards to survival and freedom-from-reintervention after eight years. Open aortic repair has been performed for more than seven decades and especially for the younger patients with few comorbidities, results are excellent. Potential drawbacks of open repair like incisional hernias, erectile dysfunction and quality of life can either be effectively prevented (mesh reinforcement) or actually failed to show a significant difference compared to open repair in recent studies. Therefore, meticulous assessment of patient comorbidites using validated parameters is the key element for decision-making and parameters such as young age, low comorbidity profile, large aneurysm and presence of atopic renal arteries or a dominant inferior mesenteric artery should prompt a recommendation of open repair.

Schlüsselwörter

Aortenchirurgie - endovaskuläre Therapie - infrarenales Aortenaneurysma - Langzeitergebnis - Operabilität

Keywords

Differential indication - Endovascular treatment - Survival - Aortic surgery - Infrarenal aortic aneurysm

Publication History

Received: 29 July 2021

Accepted after revision: 23 August 2021

Article published online:
19 October 2021

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