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Hybridverfahren zur Therapie thorakoabdomineller Aortenaneurysmen (TAAA)

Erste Erfahrungen an einem Hochrisikokollektiv

Hybrid procedure for treatment of thoracoabdominal aortic aneurysms (TAAA)

Initial experience in a high-risk population

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Zusammenfassung

Einleitung

Der offene Aortenersatz zur Therapie thorakoabdomineller Aortenaneurysmen ist komplikationsträchtig. Die kombinierte Therapie aus endovaskulärer TAAA-Ausschaltung und proximaler/distaler Umleitung supraaortaler Gefäße sowie der Viszeral- und Nierenarterien (Debranching) könnte eine technische Alternative für den Hochrisikopatienten darstellen.

Patienten und Methoden

Wir berichten über eine konsekutive prospektive Serie von 47 TAAA-Patienten (weiblich 29,8%, medianes Alter 65,5 Jahre, 37–81 Jahre, n=44/47 ASA-Stadium >3). In 51% der Fälle handelte es sich um ein arteriosklerotisches TAAA, bei 38,3% lag eine sekundär expandierende Aortendissektion Typ B und bei 10,6% eine Plaqueruptur bzw. ein aneurysmatisch erweiterter Carrell-Patch vor.

6 Patienten (12,6%) wurden notfallmäßig aufgrund einer freien oder gedeckten Aortenruptur behandelt, 21,3% hatten Rückenschmerzen und 66% waren asymptomatisch. In 55,3% bzw. 23,4% lag ein langstreckiges TAAA entsprechend der Crawford-Stadien II und III vor. Der maximale TAAA-Durchmesser betrug im Median 74 mm (45–120 mm). 57,4% der Patienten waren an der abdominellen oder thorakalen Aorta voroperiert.

Bei 7 Patienten (14,9%) erfolgte zunächst ein proximales Debranching zur Schaffung einer proximalen Landungszone zeitversetzt zur Hybridoperation. In 51% der Fälle musste zur Schaffung einer distalen Landungszone die infrarenale Aorta prothetisch ersetzt werden. Die Operationsdauer betrug im Median 368 min für den abdominellen Eingriff bzw. 499 min (250–935 min) für die gesamte Prozedur. Alle Patienten wurden mittels Spiral-CT prospektiv dokumentiert und in einem sechsmonatigen Intervall klinisch und computertomographisch untersucht.

Ergebnisse

Die 30-Tage-Mortalität betrug insgesamt 12,6% (6/47 Patienten), beim nichtrupturierten TAAA 7,4% (3/41 Patienten). Die Paraparese-/Paraplegierate lag bei 4,2% bzw. 8,5%. Bei 8,5% trat postoperativ eine dialysepflichtige Niereninsuffizienz auf. Der mittlere Krankenhausaufenthalt betrug 21,3–26 Tage (11–68), der mediane Intensivaufenthalt 9 Tage (2–31).

Die postoperative CT-Untersuchung zeigte 11 Endoleaks bei 10 Patienten (Typ I n=6, Typ II n=4, Type III n=1) sowie 7 Bypassverschlüsse (nur Nierenarterien). Typ-I- und -III-Endoleaks wurden endovaskulär korrigiert.

Schlussfolgerungen

Die Hybridoperation stellt für den Risikopatienten eine technisch und logistisch herausfordernde Alternative zum konventionellen thorakoabdominellen Aortenersatz dar. Zur Optimierung der Ergebnisse muss das Verfahren weiterhin im Vergleich zum konventionellen Standard prospektiv evaluiert werden.

Abstract

Introduction

Open replacement of the aorta for treatment of thoracoabdominal aortic aneurysms (TAAA) is liable to complications. The combination therapy consisting in endovascular bypass of the TAAA and proximal/distal diversion of supraaortal vessels and of the visceral and renal arteries (debranching) could be a technical alternative for the high-risk patient.

Patients and methods

We report on a consecutive prospective series of 47 patients with TAAA (29.8% female; median age 65.5 years, range 37–81 years; 44 in ASA stage >3). In 51% of cases the aneurysm was an arteriosclerotic TAAA, while in 38.3% a secondarily expanding type B aortic dissection was present and in 10.6%, a plaque rupture or a Carrel patch stretched by an aneurysm.

Six patients (12.6%) were treated as emergencies because of a free or concealed aortic rupture; 21.3% had back pain, and 66% had no symptoms. In 55.3% and in 23.4% a TAAA affecting a long section of the aorta and classifiable as Cawford extents II or III, respectively, was present. The median maximum diameter of a TAAA in this series was 74 mm (range 45–120 mm), and 57.4% of the patients had already undergone surgery of the abdominal or thoracic aorta previously.

In 7 patients (14.9%) proximal debranching was first performed to create a proximal landing area offset in time against the hybrid operation. In 51% of patients it was necessary to replace the infrarenal aorta with a prosthesis before a distal landing area could be created. The median duration of surgery was 368 min for the abdominal intervention and 499 (range 250–935) min for the entire procedure. All patients underwent clinical examination and spiral CT investigation at 6-month intervals with prospective documentation.

Results

The 30-day mortality was 12.6% (6/47 patients) for the whole series and 7.4% (3/41) for those with nonruptured TAAA. The corresponding paraparesis/paraplegia rates were 4.2% and 8.5%. In 8.5% renal insufficiency requiring dialysis arose in the postoperative period. The mean length of stay in hospital was 21.3–26 (11–68) days and the mean length of stay in the intensive care unit, 9 (2–31) days.

The postoperative CT investigation showed 11 endoleaks in 10 patients (type I n=6; type II n= 4; type III n=1) and 7 occluded bypasses (only renal arteries). Type I and II endoleaks were corrected by endovascular techniques.

Conclusions

The hybrid operation is a technically and logistically challenging alternative to conventional thoracoabdominal aortic replacement for the high risk patient. To optimise the result, the procedure must be evaluated prospectively against the conventional standard treatment.

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Correspondence to O. Wolf or D. Böckler.

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Die Autoren O. Wolf und D. Böckler sind gleichberechtigte Erstautoren.

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Wolf, O., Böckler, D., Heider, P. et al. Hybridverfahren zur Therapie thorakoabdomineller Aortenaneurysmen (TAAA). Gefässchirurgie 12, 338–347 (2007). https://doi.org/10.1007/s00772-007-0553-9

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