Gesicherte Operationsindikationen für thorakale Aortenaneurysmen

Zusammenfassung

Thorakale Aortenaneurysmen werden häufig zufällig detektiert. Durch ihre potenziellen Komplikationen, wie Ruptur und Aortendissektion, stellen sie eine lebensbedrohliche Erkrankung dar. Typische Risikofaktoren stammen aus dem Kreis der kardiovaskulären Erkrankungen, wie z. B. arterielle Hypertonie, positive Familienanamnese, Atherosklerose, Rauchen und chronisch obstruktive Lungenerkrankungen. Weiterhin werden auch angeborene Bindegewebserkrankungen als prädisponierende Risikofaktoren akzeptiert. Neben morphologischen Faktoren (z. B. Diameter und Form des Aneurysmas) beeinflussen auch Begleiterkrankungen und eine genetische Disposition das Rupturrisiko. Hierbei liegt die 5-Jahres-Überlebensrate bei konservativer Behandlung bei 13 %, gegenüber 70–79 % bei chirurgischer Sanierung. Grundsätzlich stehen zur Therapie des thorakalen Aortenaneurysmas medikamentöse, chirurgische und interventionelle Strategien zur Verfügung. Der folgende Artikel soll einen Überblick über die Indikationen für einen chirurgischen oder interventionellen Angang geben.

Abstract

Thoracic aortic aneurysms are associated with high morbidity and mortality due to rupture and dissection. Conservative medical treatment is associated with a 5-year survival rate of 13 %. This rises to 70–79 % in case of surgical treatment. While classical surgical strategies still dominate the care for acute and chronic pathology of the ascending aorta and the proximal arch region, new endovascular concepts are emerging and are likely to evolve as primary treatment strategies for descending aortic pathology in suitable patients.

Schlüsselwörter

Aortenaneurysma - Aortenruptur - Aortendissektion - offene Chirurgie - Stentgraft

Keywords

aortic aneurysm - aortic rupture - aortic dissection - open surgery - stentgraft

• Literatur

• 1 Erbel R, Aboyans V, Boileau C et al. 2014 ESC Guidelines on the diagnosis and treatment of aortic disease: Document covering acute and chronic aortic disease of the thoracic and abdominal aorta of the adult. The task force for the diagnosis and treatment of aortic diseases of the European Society of Cardiology (ESC). Eur Heart J 2014; 1: 2873-2926
• 2 Svensson LG, Kouchoukos NT, Miller DC et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg 2008; 85: S1-41
• 3 Crawford ES, Crawford JL, Safi HJ et al. Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients. J Vasc Surg 1986; 3: 389-404
• 4 Olsson C, Thelin S, Stahle E et al. Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14 000 cases from 1987 to 2002. Circulation 2006; 114: 2611-2618
• 5 Crawford ES, Cohen ES. Aortic aneurysm: a multifocal disease. Arch Surg 1982; 117: 1393-1400
• 6 Hagan PG, Nienaber CA, Isselbacher EM et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283: 897-903
• 7 Kato M, Bai H, Sato K et al. Determining surgical indications for acute type B dissection based on enlargment of aortic diameter during the chronic phase. Circulation 1995; 92: II107-112
• 8 Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation 2005; 111: 816-828
• 9 Lilienfeld DE, Gunderson PD, Sprafka JM et al. Epidemiology of aortic aneurysms: I. Mortality trends in the United States, 1951 to 1981. Arteriosclerosis 1987; 7: 637-643
• 10 Crawford ES, DeNatale RW. Thoracoabdominal aortic aneurysm: observations regarding the natural course of the disease. J Vasc Surg 1986; 3: 578-582
• 11 Clouse WD, Hallett Jr JW, Schaff HV et al. Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA 1998; 280: 1926-1929
• 12 Elefteriades JA. Natural history of thoracic aortic aneurysms: indications for surgery, and surgical versus nonsurgical risks. Ann Thorac Surg 2002; 74: S1877-1880
• 13 Coselli JS, LeMaire SA, Miller 3rd CC et al. Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis. Ann Thorac Surg 2000; 69: 409-414
• 14 Yacoub MH, Gehle P, Chandrasekaran V et al. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg 1998; 115: 1080-1090
• 15 Nienaber CA, Fattori R, Lund G et al. Nonsurgical reconstruction of thoracic aortic disection by sten-graft placement. N Engl J Med 1999; 340: 1539-1545
• 16 Fann JI, Miller DC. Endovascular treatment of descending thoracic aortic aneurysm and dissections. Surg Clin Nortg Am 1999; 79: 551-574
• 17 Fattori R, Nienaber CA, Rousseau H et al. Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg 2006; 132: 332-339
• 18 Ellozy SH, Carroccio A, Minor M et al. Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned. J Vasc Surg 2003; 38: 676-683
• 19 Demers P, Miller DC, Mitchell RS et al. Midterm results of endovascular repair of descending thoracic aortic aneurysms with first-generation stent grafts. J Thorac Cardiovasc Surg 2004; 127: 664-673
• 20 Nienaber CA, Rousseau H, Eggebrecht H et al. Randomized comparison of strategies for type B aortic dissection: the Investigation of Stent Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009; 120: 2519-2529
• 21 Nienaber CA, Kische S, Rousseau H et al. Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv 2013; 6: 407-416
• 22 Jonker FH, Trimarchi S, Verhagen HJ et al. Meta-analysis of open versus endovascular repair repair for ruptured descending thoracic aortic aneurysm. J Vasc Surg 2010; 51: 1026-1032
• 23 Patel HJ, Williams DM, Upchirch Jr GR et al. A comparative analysis of open and endovascular repair fort he ruptured descending thoracic aorta. J Vasc Surg 2009; 50: 1265-1270
• 24 Hooper WL. Haematemesis and melaena due to rupture of a saccular aneuysm of the aorta into the oesophagus. Postgrad Med J 1962; 38: 297-301
• 25 Dossa CD, Pipinos II, Shepard AD et al. Primary aortoenteric fistula: Part II, Primary aortoesophageal fistula. Ann Vasc Surg 1994; 8: 207-211
• 26 Coselli JS, Crawford ES. Primary aortoesophageal fistula from aortic aneurysm: successful surgical treatment by use of omental pedicle graft. J Vasc Surh 1990; 12: 269-277
• 27 Pipinos II, Reffy DJ. Secondary aortoesophageal fistulae. Ann Vasc Surg 1999; 13: 649-652
• 28 Chiesa R, Melissano G, Marone EM et al. Endovascular treatment of aortoesophageal and aortobronchial fistulae. J Vasc Surg 2010; 51: 1195-1202