Antithrombotische Therapie nach peripheren Gefäßeingriffen. Was ist evidenzbasiert?

Zusammenfassung

Die periphere arterielle Verschlusskrankheit ist eine Manifestation der Systemerkrankung Atherosklerose. Die initiale Therapie jeder atherosklerotischen Gefäßerkrankung zielt auf eine Reduktion kardiovaskulärer Risikofaktoren durch Lebensstilmodifikation und medikamentöse Maßnahmen. Patienten, die sich einer operativen Revaskularisation im peripheren Gefäßsystem unterziehen müssen, benötigen zudem eine langfristige antithrombozytäre Therapie bzw. Antikoagulation, die differenziert nach dem befallenen vaskulären Territorium und der verwendeten Methode zur Revaskularisation gestaltet werden muss. Die aktuelle Studienlage empfiehlt in der Langzeittherapie nach lokaler Thrombendarteriektomie und nach alloplastischen (Dacron, PTFE) Bypässen der aortalen und supragenualen Region ASS 100 mg/d oder Clopidogrel 75 mg/d. Nach Anlage kniegelenksüberschreitender alloplastischer Bypässe ist die Kombination von ASS 100 mg/d und Clopidogrel 75 mg/d empfohlen. Demgegenüber profitieren in der Langzeittherapie nach autologer (v. a. venöser) Bypassanlage jeglicher Region Patienten von einer oralen Antikoagulation mit Vit.-K-Antagonisten (INR 2–3), wenn ein niedriges Blutungsrisiko besteht. Bei Kontraindikationen empfiehlt sich die Gabe von ASS 100 mg/d. Im weiteren Verlauf ist eine systematische Kontrolle der Gefäßrisikofaktoren, des Gefäßstatus, der Antikoagulation bzw. der antithrombotischen Therapie indiziert.

Abstract

Peripheral arterial occlusive disease is one manifestation of the systemic disease atherosclerosis. The initial therapy for every arteriosclerotic disease is aimed at reducing cardiovascular risk factors by lifestyle modification and medication. Patients who require surgical revascularisation need long-term antiplatelet therapy or anticoagulation. This therapy has to be differentiated according to the vascular territory involved and the method used for revascularisation. After local thrombendarterectomy, alloplastic bypass graft surgery of the aortic, aorto-iliac, aorto-femoral or femoro-popliteal region above the knee, long-term ASA 100 mg/d or clopidogrel 75 mg/d should be initiated. After alloplastic bypass grafting below the knee the combination of ASA 100 mg/d and clopidogrel 75 mg/d should be used. In contrast, after venous grafts the patency rate is improved by anticoagulation with vitamin K antagonists (INR 2–3), if there is a low risk of bleeding. If there is a contraindication to vitamin K antagonists, ASA 100 mg/d should be used. After revascularisation, a structured surveillance programme should be implemented aiming at controlling cardiovascular risk factors and monitoring the vascular state, as well as the anticoagulation and the antiplatelet therapy.

Schlüsselwörter

Bypass-Chirurgie - Bypass-Material - Antikoagulation

Key words

bypass surgery - bypass material - anticoagulation

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