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Aneurysmen der Bauchaorta und der Beckenarterien

Paradigmenwechsel – operative Therapie, wenn möglich endovaskulär?

Aneurysms of the abdominal aorta and iliac arteries

Paradigm shift – operative therapy, if possible endovascular?

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Zusammenfassung

Hintergrund

Die Therapie des Bauchaortenaneurysmas („abdominal aortic aneurysm“, AAA) ist heute auf hohem Evidenzniveau gesichert. Das gilt nicht in gleicher Weise für das Beckenarterienaneurysma („iliac artery aneurysm“, IAA). IAAs sind häufig mit einem AAA assoziiert und treten nur selten isoliert auf. Therapieprinzipien gelten für beide Aneurysmalokalisationen in analoger Weise.

Ziel der Arbeit

Neue Erkenntnisse, Fortschritte der perioperativen Medizin und die rasante Entwicklung der minimal-invasiven Technik erfordern regelmäßig eine aktuelle Standortbestimmung (Update), die in dieser Arbeit zur Therapie des AAA und IAA erfolgen soll.

Material und Methoden

Eine systematische Literaturrecherche wurde in PubMed und Medline vorgenommen. Dabei wurden vorrangig rezente Publikationen auf höherem Evidenzniveau berücksichtigt.

Ergebnisse

EVAR („endovascular aneurysm repair“) und OAR („open aneurym repair“) sind gleichwertige Methoden zur Behandlung des AAA bezüglich des Langzeitüberlebens der Patienten. Ein perioperativer Überlebensvorteil nach EVAR persistiert lediglich mittelfristig postoperativ. Die Reinterventionsrate nach EVAR ist gegenüber OAR deutlich erhöht. Für ältere Patienten und solche, für die eine OAR nicht mehr infrage kommt, konnte der erwartete Vorteil der EVAR bis dato nicht bewiesen werden. Aneurysmarupturen nach EVAR zeigen, dass eine lebenslange Kontrolle dieser Patienten erforderlich ist.

Diskussion

Die elektive Therapie des AAA und IAA erfolgt zunehmend endovaskulär (EVAR). Auch komplexe Aneurysmen sind überwiegend minimal-invasiv behandelbar. Dennoch existiert auch weiterhin die Indikation zur offenen Aneurysmaausschaltung (OAR). Ein AAA-Screening führt zu einer Verminderung von Aneurysmarupturen, für die die EVAR ebenfalls zunehmende Bedeutung erlangt.

Abstract

Background

Therapy of abdominal aortic aneurysms (AAA) is currently based on a high level of evidence. This is not true in the same manner for iliac artery aneurysms (IAA) which are frequently associated with AAAs and occur only rarely as isolated lesions. The therapeutic principles apply in the same way to both aneurysm locations.

Objectives

New findings, improved perioperative care and the rapid development of minimally invasive techniques require a constant update which is the aim of this article concerning the therapy of AAAs and IAAs.

Material and methods

A systematic literature review was performed in PubMed and Medline and priority was given to recent publications with a high level of evidence.

Results

Endovascular aneurysm repair (EVAR) and open aneurysm repair (OAR) result in a similar long-term survival. The perioperative survival advantage with EVAR persists only during medium-term postoperative courses. The reintervention rate after EVAR is substantially higher compared to OAR. For older patients and those who are considered unfit for OAR the expected benefits from EVAR has not been proven to date. Aneurysmal ruptures after EVAR demonstrate that a life-long surveillance of these patients is necessary.

Conclusion

Therapy of AAAs and IAAs is increasingly being performed by EVAR. Even the majority of complex aneurysms are amenable to minimally invasive treatment. Nevertheless, indications for OAR continue to exist. Screening for AAAs results in a decrease of aneurysmal ruptures for which EVAR is also gaining importance.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. R.I. Rückert, U. Hanack, S. Aronés-Gomez und S. Yousefi geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Klinik für Gefäß- und endovaskuläre Chirurgie, Allgemein- und Viszeralchirurgie Franziskus-Krankenhaus, Akademisches Lehrkrankenhaus der Charité, Universitätsmedizin Berlin, Budapester Str. 15–19, 10787, Berlin, Deutschland

    R.I. Rückert, U. Hanack, S. Aronés-Gomez & S. Yousefi

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  1. R.I. Rückert
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Rückert, R., Hanack, U., Aronés-Gomez, S. et al. Aneurysmen der Bauchaorta und der Beckenarterien. Chirurg 85, 782–790 (2014). https://doi.org/10.1007/s00104-014-2718-x

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