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Aktuelle Studienlage zur Shuntchirurgie

Current study situation on shunt surgery

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Zusammenfassung

Ein funktionierender Gefäßzugang ist eine Grundvoraussetzung für die lebenserhaltende Dialysebehandlung bei Patienten mit chronischem Nierenversagen. Komplikationen dieser Gefäßzugänge gehören zu den wesentlichen Gründen der hohen Morbidität und Letalität von dialysepflichtigen Patienten. Das Outcome des Dialyseshunts und damit auch die Lebensqualität des Patienten sind maßgeblich beeinflusst durch das Timing der Shuntanlage, die Selektion der Gefäßregion, die Wahl des Shuntverfahrens sowie die adäquate Nachsorge. Eine autologe arteriovenöse (a.v.) Fistel wird als primärer Dialysezugang angestrebt. Sie bietet im Vergleich zu alloplastischen Materialien (Shuntprothesen, Dialysekatheter) die besten Offenheits- und die geringsten Komplikationsraten. Shuntprothesen sind u.a. aufgrund ihrer hohen Verschlussraten Dialysezugänge der zweiten Wahl. Insbesondere durch pharmakologische oder neue technische Ansätze haben sich erste Fortschritte bei der Verhinderung der durch die neointimalen Hyperplasie bedingten Anastomosenstenosen von Dialyseshunts ergeben. Neue Thrombektomiekatheter haben die Ergebnisse der interventionellen Wiedereröffnung von verschlossenen Shunts zwar deutlich verbessert, jedoch die chirurgischen Verfahren nicht verdrängt. Die Behandlung von Shuntstenosen ist zunehmend eine Domäne der interventionellen Methoden, wobei sich hier momentan abhängig von der Stenosenlokalisation und -ursache verschiedene Therapieempfehlungen über die alleinige Ballonangioplastie hinaus entwickeln. Shuntinduzierte Steal-Syndrome erfordern ein differenziertes Therapiekonzept, das unterschiedliche Faktoren wie das Flussvolumen des Shuntes und seine Lokalisation sowie den Gefäßstatus und die Komorbidität des Patienten berücksichtigen sollte.

Abstract

A well-functioning vascular access is a prerequisite for life-sustaining dialysis treatment in patients with chronic renal failure. Complications of a vascular access belong to the major causes of the high morbidity and mortality in dialysis-dependent patients. The outcome of the dialysis access and patient’s quality of life is dependent on the timing of access creation, selection of the appropriate vascular region, type of access and the follow-up. Autologous arteriovenous (a.v.) fistulae are considered to be the first choice dialysis access. Compared to an alloplastic access (prosthetic grafts, dialysis catheters) a.v. fistulae offer the highest patency and lowest complication rates. Autologous arteriovenous grafts remain the second choice for dialysis access mainly due to high occlusion rates. Particularly pharmacological and new technical approaches have recently provided further progress in prevention of anastomotic stenoses caused by neo-intimal hyperplasia. Access complications are increasingly being managed by interventional therapy. New thrombectomy devices have improved results of interventional revascularization of occluded a.v. accesses but up to now have not replaced surgical techniques. Stenotic lesions of dialysis accesses are predominantly treated by interventional methods. Apart from the sole use of balloon angioplasty, different recommendations for additional interventions have emerged depending on shunt localization and type of stenosis. Shunt-induced steal syndromes require differentiated therapy which considers factors such as access flow and localization as well as vascular status and patient co-morbidities.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Sektion Gefäßchirurgie - Endovaskuläre Chirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 9, 97080, Würzburg, Deutschland

    R. Kellersmann

  2. Fachbereich Gefäßchirurgie, Kreiskrankenhaus Rastatt, Klinikum Mittelbaden, Rastatt, Deutschland

    V. Mickley

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Kellersmann, R., Mickley, V. Aktuelle Studienlage zur Shuntchirurgie. Gefässchirurgie 15, 579–588 (2010). https://doi.org/10.1007/s00772-010-0813-y

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