Läsionspräparation bei peripheren Arterien – Fact or Fashion?

Zusammenfassung

Die periphere arterielle Verschlusskrankheit (pAVK) ist in dem überwiegenden Anteil der Fälle durch stenosierende atherosklerotische Läsionen der peripheren Arterien der unteren Extremität bedingt. Neben asymptomatischen Verläufen ist die intermittierende Claudicatio-Symptomatik die häufigste Manifestation, im fortgeschritteneren Stadium der Erkrankung tritt eine chronische extremitätenbedrohende Ischämie (CLTI) auf. Die konservativ-medikamentöse sekundärpräventive Therapie repräsentiert einen wesentlichen Grundpfeiler in allen Stadien der pAVK, während die endovaskuläre und die offene gefäßchirurgische Revaskularisation je nach Patienten- und Läsionsmerkmalen einen hohen Stellenwert besitzen und komplementär oder kombiniert zum Einsatz kommen können. Bei Patienten mit Claudicatio ist die Verbesserung der schmerzfreien Gehstrecke das primäre Therapieziel, während bei Patienten mit CLTI das amputationsfreie Überleben im Vordergrund steht. In beiden Patientengruppen besteht die Notwendigkeit der strengen Kontrolle der kardiovaskulären Risikofaktoren, inkl. der Blutdruck- und Diabeteseinstellung, Nikotinkarenz und Reduktion der Cholesterinwerte mittels intensiver Statintherapie, gemäß nationalen und internationalen Leitlinien. Die endovaskuläre Behandlung der pAVK wird breitflächig und von verschiedenen Fachdisziplinen eingesetzt. Herkömmliche endovaskuläre Therapieverfahren weisen jedoch bei komplexen und stark kalzifizierten Läsionen Limitationen auf, sodass z. B. die klassische Ballonangioplastie bei solchen Läsionen mit „Recoil“ (Zusammenziehen) und/oder schweren Dissektionen (Gefäßeinrisse bis hin zum Gefäßverschluss) assoziiert ist, die i. d. R. eine Stentimplantation erforderlich machen. Verfahren zur Läsionspräparation wie die Atherektomie und die intravaskuläre Lithotripsie (IVL) können die Compliance von verkalkten Arterien verbessern, indem entweder Mikrofrakturen an verkalkten Stellen verursacht werden oder kalzifiziertes Material entfernt wird. Auf diesem Weg kann anschließend eine Ballonangioplastie mit weniger Barotrauma erfolgen und die Notwendigkeit der Stentimplantation reduziert werden, während die nachfolgende Behandlung mit medikamentenbeschichteten Ballons (DCB) mit einer potenziell verbesserten Penetration des Medikamentes in die Gefäßwand einhergeht, sodass die Wirksamkeit der entsprechenden antirestenotischen Effekte erhöht werden kann. Im Folgenden werden Möglichkeiten und Grenzen der verschiedenen Läsionspräparationsverfahren und sowie die aktuelle Studienlage vorgestellt und diskutiert.

Abstract

Peripheral arterial disease (PAD) is mostly caused by stenotic atherosclerotic lesions of lower limb arteries. Intermittent claudication is the most common manifestation, while, in more advanced stages of the disease, chronic limb-threatening ischemia (CLTI) occurs. Optimal medical therapy is an essential cornerstone in all stages of PAD, while endovascular and open surgical revascularisation are of great importance – depending on the patient and lesion characteristics and can be used in a complementary manner. In patients with claudication, the improvement in the pain-free walking distance is the primary therapeutic goal, while, in patients with CLTI, amputation-free survival is most important. In both patient groups, there is a need for strict control of cardiovascular risk factors, including blood pressure and diabetes control, nicotine abstinence and reduction in cholesterol levels using intensive statin therapy, in accordance with national and international guidelines. Endovascular treatment of PAD is used widely and by various specialist disciplines. However, conventional endovascular therapy procedures have limitations in complex and heavily calcified lesions, so that, for example, classic balloon angioplasty in such lesions is associated with “recoil” and/or severe dissections, which usually require the placement of permanent metallic implants. Lesion preparation procedures, such as atherectomy and intravascular lithotripsy (IVL) can improve compliance of calcified arteries, by either creating microfractures at calcified sites or removing calcified material. In this way, balloon angioplasty can be performed with less barotrauma and the need for stent implantation can be reduced, while subsequent treatment with drug-coated balloons (DCB) is associated with potentially improved penetration of the drug into the vessel wall, and thus increases the effectiveness of the procedure by enhancing anti-restenotic effects. In this manuscript, the potential – but also the limitations – of different lesion preparation strategies are presented and discussed.

Schlüsselwörter

Angioplastie - endovaskuläre Therapie - Arteria femoralis superficialis - Spezialballonkatheter - chronischer Verschluss - Läsionspräparation

Keywords

angioplasty - endovascular treatment - superficial femoral artery - specialty balloons - chronic total occlusion - lesion preparation

Publikationsverlauf

Eingereicht: 26. Mai 2024

Angenommen: 06. Februar 2025

Artikel online veröffentlicht:
14. März 2025

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