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Was ist gesichert in der interventionellen Therapie der peripheren arteriellen Verschlusskrankheit?

Mobilität der Patienten erhalten

Recommended interventions for the treatment of peripheral artery disease

Keep the patients moving

  • Schwerpunkt: Was ist gesichert in der Therapie?
  • Published:
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Zusammenfassung

Hintergrund

Die periphere arterielle Verschlusskrankheit (PAVK) wird häufig erst in fortgeschrittenen Stadien diagnostiziert. Entsprechend spät erfolgt die Revaskularisierung.

Fragestellung

Im vorliegenden Beitrag werden die Progression zur kritischen Ischämie und das kardiovaskuläre Risiko beschrieben. Die Sekundärprävention durch Revaskularisierung wird erläutert. Dabei wird auf die Methoden der Revaskularisierung in Abhängigkeit von der Lokalisation und Komplexität der Stenosen oder Verschlüsse eingegangen.

Material und Methoden

Die aktuellen Leitlinien sowie randomisierte Studien und Metaanalysen werden analysiert.

Ergebnisse

Die PAVK ist mit einem erheblichen Leidensdruck und hohen kardiovaskulären Risiko verbunden. Bei bis zu 20 % der Patienten mit Claudicatio kommt es zur Progression in die kritische Ischämie. Progression und Mortalitätsrisiko nehmen im Verlauf der Erkrankung zu. Die durch Revaskularisierung verbesserte Gehfähigkeit ist eine wichtige Säule der Sekundärprävention. Im femoropoplitealen Segment sind die Angioplastie mit medikamentenbeschichteten Ballons (DCB) und die Implantation von „bare metal stents“ (BMS) Behandlungsmethoden der Wahl. Bei langen Läsionen sollte, falls erforderlich, dem Spot-Stenting gegenüber der langstreckigen Stentversorgung der Vorzug gegeben werden. Bei In-Stent-Restenosen haben sich DCB und bei schweren Verkalkungen oder Dissektionen BMS bewährt. Im infrapoplitealen Segment haben sich DCB und medikamentenbeschichtete Stents verglichen mit „plain old balloon angioplasty“ oder BMS als wirksamer erwiesen. Falls nötig ist eine infrapopliteale Revaskularisierung zur Verbesserung der pedalen Versorgung indiziert.

Abstract

Background

Peripheral artery disease (PAD) is often diagnosed in an advanced stage. Accordingly, revascularization is also performed late.

Objectives

In this paper, the authors describe the progression to critical limb ischemia and cardiovascular risk. Revascularization for secondary prevention is explained. Revascularization strategies according to lesion location and complexity of the stenosis or occlusion are discussed.

Materials and methods

The current guidelines and randomized controlled studies and meta-analyses are analyzed.

Results

PAD is associated with a considerable level of suffering and a high cardiovascular risk. Up to 20% of patients with claudicants will progress to critical limb ischemia. Progression and risk of mortality increase during the course of the disease. Improvement of walking ability by revascularization is a major goal of secondary prevention. In the femoropopliteal segment, drug-coated balloon (DCB) angioplasty and bare-metal stent (BMS) implantation are the methods of choice. In long lesions, spot-stenting should be preferred. For treatment of in-stent restenosis, DCB have proven their effectiveness. In severely calcified or dissected lesions, BMS are well suited. Infrapopliteal lesions should be revascularized to provide in-line flow to the foot through the target arterial path. According to current evidence, DCB or drug-eluting stents are more effective than plain old balloon angioplasty or BMS.

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Danksagung

Der Autor dankt Dr. Maja Ingwersen für die Unterstützung beim Erstellen des Manuskripts.

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  1. Zentrum für Gefäßmedizin, Abteilung Angiologie, Asklepios Klinikum Harburg, Eißendorfer Pferdeweg 52, 21075, Hamburg, Deutschland

    H. Krankenberg

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Correspondence to H. Krankenberg.

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H. Krankenberg gibt an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden vom Autor keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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H. Haller, Hannover

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Krankenberg, H. Was ist gesichert in der interventionellen Therapie der peripheren arteriellen Verschlusskrankheit?. Internist 60, 1235–1239 (2019). https://doi.org/10.1007/s00108-019-00695-x

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