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Gefäßmedizin Scan - Zeitschrift für Angiologie, Gefäßchirurgie, diagnostische und interventionelle Radiologie 2021; 08(01): 53-68
DOI: 10.1055/a-1348-7873
CME-Fortbildung

Rekanalisationen im femoropoplitealen und kruropedalen Segment bei pAVK

Peter Huppert
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Mit pAVK (peripherer arterieller Verschlusskrankheit) einhergehende Gefäßverschlüsse und -stenosen manifestieren sich als Claudicatio intermittens oder in fortgeschrittenem Stadium als kritische Extremitätenischämie. Vor allem bei Letzterer bestimmt eine schnelle, effektive Revaskularisation den Therapieerfolg. Der Beitrag schildert die geeigneten Zugangswege, Materialien und Rekanalisierungstechniken im femoropoplitealen und kruropedalen Segment
Kernaussagen

  • Interventionelle Rekanalisationen zur Behandlung bei pAVK zielen bei Patienten im Stadium der Claudicatio intermittens auf eine dauerhafte Verbesserung der muskulären Durchblutung, im Stadium der kritischen Ischämie auf die Beseitigung des Ruheschmerzes und die Abheilung der Gewebedefekte.

  • Bei Claudicatio intermittens ist das Gehtraining die Therapie der ersten Wahl. Ist dies nicht möglich oder erfolglos, ist eine interventionelle Revaskularisation indiziert. Bei kritischer Extremitätenischämie ist eine schnelle und effektive Revaskularisation entscheidend.

  • Für die femoropopliteale Intervention wird meist der transfemoral-antegrade Zugang gewählt, in Ausnahmefällen ein Cross-over-Zugang. Scheitern die Techniken der antegraden Passage, kann eine retrograde Passage versucht werden. Ähnliches gilt für Revaskularisationen im kruropedalen Segment.

  • Für die Rekanalisation komplexer Gefäßverschlüsse wird die Strategie der Eskalation verschiedener Techniken empfohlen. Ist mit verschiedenen Führungsdrähten die Verschlusspassage nicht möglich, kann ein Re-Entry-System oder die intendiert subintimale Passage hilfreich sein.

  • Nach gelungener Drahtpassage muss ein ausreichendes Gefäßlumen mittels Ballonangioplastie mit Bail-out-Stenting etabliert werden. Drug-eluting Devices senken dabei die Reinterventionsrate im femoropoplitealen Segment.

  • Die temporäre Offenheit infrapoplitealer Arterien ist oft ausreichend für die meist 3–6 Monate andauernde Phase der Abheilung von Gewebedefekten und damit den Erhalt der Extremität (Limb Salvage).

  • Als medikamentöse Begleittherapie wird vor und nach der Intervention ASS gegeben, um nach der Intervention einen Reverschluss zu vermeiden. Nach Rekanalisation komplexer Gefäßverschlüsse wird eine mindestens 4-wöchige duale Thrombozytenaggregationshemmung empfohlen. Die Kombination mit direkten Antikoagulanzien verringert potenziell ischämische Komplikationen nach Revaskularisationen.



Publication History

Article published online:
10 March 2021

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