Behandlung der Aortenisthmusstenose bei Erwachsenen – Update 2016

Abstract

Coarctation accounts for 5 – 8 % of congenital cardiovascular defects and confers premature death, stroke, left ventricular hypertrophy, heart failure and/or bleeding collateral neovessels. With the therapeutic consensus that any trans-coarctation gradient needs to be abolished to improve outcomes the classic management of surgical repair is being replaced by less traumatic endovascular interventions to achieve similar results at a markedly lower risk; surgical trauma and bleeding complication can be essentially avoided with the advent of suitable balloon-inflatable stents and stent grafts, as well as with self-expanding stents. This changing paradigm towards nonsurgical endovascular management is supported by improved outcome and lower morbidity with sustained control of systemic blood pressure. Both the need for continued and individualized medication and the occasional reoccurrence of a gradient warrant a life-long surveillance of any patient with adult coarctation.

Kernaussagen

• Die Aortenisthmusstenose ist mit 5 – 8 % aller kongenitalen kardiovaskulären Fehlbildungen ein relevantes Problem.

• Eine Aortenisthmusstenose geht mit einer erhöhten Sterblichkeit im mittleren Alter einher. Außerdem kann der Hypertonus zu zerebralen Ereignissen und zur linksventrikulären Hypertrophie führen. Weitere mögliche Komplikationen sind Entwicklung einer Herzinsuffizienz und/oder Blutungskomplikationen bei extensiven Kollateralneubildungen.

• Erfolgreich ist eine Behandlung, wenn sie den über die Isthmusstenose bestehenden Druckgradienten eliminieren kann.

• Das klassische chirurgische Verfahren der Resektion oder Rekonstruktion einer Isthmusstenose wird gegenwärtig von weniger traumatischen, endovaskulären Verfahren abgelöst. Mit diesem Vorgehen lassen sich vergleichbare Ergebnisse erreichen bei deutlich geringerem Risiko.

• Das chirurgische Trauma und eventuelle Blutungskomplikationen angesichts des ausgedehnten Kollateralnetzes werden vollends vermieden beim Einsatz ballonexpandierbarer oder selbstexpandierender Stents oder Stentgrafts.

• Der therapeutische Paradigmenwechsel zugunsten eines nicht chirurgischen endovaskulären Vorgehens wird von der aktuellen Datenlage unterstützt: Es gibt Belege für eine verbesserte Prognose und geringere Morbidität sowie nachhaltige Stabilisierung des Blutdrucks auf niedrigerem Niveau.

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