Endovaskuläre und kombiniert offen-chirurgische Rekonstruktion der thorakoabdominellen Aorta

Zusammenfassung

Fragestellung

Der offen-chirurgische Prothesenersatz der thorakoabdominellen Aorta ist als Verfahren der ersten Wahl mit einer relevanten perioperativen Komplikationsrate (Paraplegie, Nierenversagen) und Mortalitätsrate verbunden. Profitieren insbesondere kardiopulmonale Risikopatienten mit komplexer Aortenpathologie durch Kombination endovaskulärer und konventioneller Rekonstruktionsverfahren von den Vorteilen der minimal-invasiven endovaskulären Ausschaltung als simultanes oder sequentielles Hybridverfahren? Wir berichten über Indikationsstellung, Konzept und erste klinische Ergebnisse dieser Kombination endovaskulärer Verfahren mit konventioneller Aortenchirurgie zur Minimierung der perioperativen Belastung.

Methode und Ergebnisse

In einem Zeitraum von 3 1/2 Jahren (Oktober 1999 bis Mai 2003) wurden 19 Patienten mit komplexer thorakoabdomineller Aortenpathologie (16 Männer, 3 Frauen, Durchschnittsalter 68 Jahre) durch sehr lange (>30 cm) Aortenendoprothesen (2–4 Endoprothesen) mit Truncus-coeliacus-Okklusion (n=6) oder kombiniert mit offen-chirurgischer Revaskularisation von Viszeral- und/oder Nierenarterien versorgt (n=11). Das Indikationsspektrum umfasste 5 Patienten mit thorakoabdominellem Aneurysma (TAAA) Typ Crawford I und 1 Patient mit chronisch-expandierender B-Dissektion, 3 symptomatische Plaquerupturen bei TAAA Typ Crawford IV, 5 kombinierte thorakale Descendens-Aneurysmen und infrarenale Aortenaneurysmen mit sanduhrförmiger Aussparung des Viszeralsegments, 3 juxtarenale bzw. para-anastomosale Aneurysmen und 2 Patienten simultan mit offenem Aortenbogenersatz und Rendezvous-Manöver einer thorakalen Endoprothese mit Direktnaht an den Bogenersatz.

Schlussfolgerungen

Bei niedriger Morbidität- und Mortalitätsrate dieses Hochrisikopatientenkollektivs stellen Kombinatiosneingriffe an der thorakoabdominellen Aorta für kardiopulmonale Risikopatienten eine viel versprechendes alternatives Behandlungskonzept dar.

Abstract

Purpose

Open surgical grafting of the thoracoabdominal aorta is the method of first choice in this field. However, it is linked to a significant perioperative complication rate (paraplegia, renal failure) and mortality rate. Do risk patients with cardiopulmonary disease and complex aortic pathology particularly benefit from the advantages of minimally invasive exclusion as simultaneous or sequential hybrid procedures by combining endovascular and conventional vascular reconstruction? We report on indication, concept, and preliminary results of combining endovascular therapy with conventional aortic surgery in order to minimize the perioperative stress.

Methods and results

Over a period of 3.5 years (October 1999 to May 2003) 19 patients with complex thoracoabdominal aortic pathology (16 men, 3 women, median age: 68 years) were provided with very long (>30 cm) aortic endografts (2–4 endografts) and an occlusion of the celiac trunk (n=6) or a combination of open surgical revascularization of the visceral arteries and/or the renal arteries (n=11). The indication range covered five patients with Crawford type I thoracoabdominal aneurysms (TAAA) and one patient with chronic expanding type B dissection, three symptomatic plaque ruptures in Crawford type IV TAAA, five combined thoracic aneurysms of the descending aorta and infrarenal aortic aneurysms with an hourglass-shaped exclusion of the visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with a simultaneous open aortic arch replacement and rendezvous maneuver of a thoracic endograft with direct suture to the aortic arch replacement. Three different endograft systems were applied (Talent 6, Excluder TAG 12, Lifepath 1). Nine patients underwent elective surgery, five were hemodynamically unstable emergency cases, and five were rated urgent (contained ruptures). In five cases implantation was carried out transprosthetically via a retroperitoneal iliac Dacron conduit. Precise endograft positioning was performed during a temporary drug-induced cardiac arrest in 11 patients. Postoperative follow-ups (median follow-up: 21 months) included clinical examinations, laboratory findings, conventional X-rays (stent integrity), and CT scans or MR angiographies optimized by contrast-enhancing agents (aortic morphology). The technical success rate of all combined interventions amounts to 100%. Complications presented as two retroperitoneal hemorrhages which required revision surgery (anastomosis of the conduit) and one long-term ventilation for a period of 5 days in a patient with preexisting subglottic tracheal stenosis. One patient developed a proximal type I endoleak after chronic expanding type B dissection and thus faces conversion despite endorepair. The 30-day mortality rate of all patients (elective and emergency cases) totals 17%: one patient with an acute type A dissection died as a result of multiple organ failure 3 weeks postoperatively (initial prolonged intestinal ischemia), another one who had presented with a ruptured type A dissection died 3 weeks postoperatively due to a secondary rupture of the conventional aortic arch anastomosis (primarily chronic infection), and one patient who had undergone elective surgery died postoperatively due to a myocardial infarction. We did not observe any perioperative paraplegia or acute renal failure. After a median of 20 months the survival rate amounts to 83%.

Conclusions

Regarding the low morbidity and mortality rates in this high-risk patient population, combined intervention in the thoracoabdominal aorta can be considered a highly promising alternative therapy concept for cardiopulmonary risk patients.