Zusammenfassung
Sowohl die spontane Ruptur von Koronararterien als auch die Koronarperforation im Rahmen von Herzkathetereingriffen stellen seltene, aber potentiell lebensbedrohliche Ereignisse dar, die häufig mit der Notwendigkeit einer Notfalloperation einhergehen. Die Inzidenz von Perforationen im Zuge koronartherapeutischer Eingriffe beträgt in Abhängigkeit von den angewandten Techniken 0,1 bis 0,2% bei konventioneller Ballondilatation und bis zu 3% bei Verwendung von Koronarinstrumentarien der zweiten Generation (sogenannte „new devices”: direktionale Atherektomie, Excimer-Laser-Angioplastie, Rotablation oder Extraktionsatherektomie). Für die Therapie der akuten Koronarperforation im Katheterlabor wurden verschiedene interventionelle Strategien entwickelt. Erst in neuerer Zeit besteht jedoch durch die Verfügbarkeit koronarer Stent-Grafts eine praktikabler Ansatz, akute Perforationen gefäßerhaltend definitiv zu versorgen. Während die iatrogene Koronarperforation somit umgehend am Ort ihrer Entstehung behandelt werden kann, besteht bei der Ruptur vorbestehender, möglicherweise nicht vorbekannter Koronarveränderungen häufig ein diagnostisches Intervall, welches zur Ausbildung entsprechender klinischer Ereignisse (Myokardinfarkt, Herzbeuteltamponade, maligne Arrhythmien, plötzlicher Herztod) beiträgt. Es erscheint gerechtfertigt, auch bei inzidentieller Diagnosestellung rupturgefährdeter Koronarien eine prophylaktische Versorgung vorzunehmen. Diese kann entweder operativ oder, in geeigneten Fällen, interventionell erfolgen. Die Implantation koronarer Stent-Grafts könnte sich hierbei aufgrund der technisch einfachen und sicheren Prozedur sowie des kurzen Krankenhausaufenthalts als Therapie der Wahl etablieren. Bevor jedoch eine generelle Empfehlung zur Ausweitung des Indikationsspektrums dieser neuartigen Koronarimplantate gegeben werden kann, sind kontrollierte Studien mit klinischer und angiographischer Langzeitnachbeobachtung zu fordern.
Abstract
Spontaneous rupture of coronary arteries as well as coronary perforation during percutaneous interventions are rare but potentially life-threatening incidents often resulting in emergency surgery. Frequency of acute perforation due to therapeutic catheterization varies according to the devices employed. With conventional balloon angioplasty it is estimated to be 0.1 to 0.2% whereas substantially higher rates of up to 3% have been reported with the use of so-called “new devices” (i. e. directional atherectomy, rotablation, excimer laser angioplasty or extractional atherectomy). Interventional strategies for nonsurgical treatment of acute coronary perforations during catheterization procedures have been developed. In recent times, availability of coronary stentgrafts allows for a percutaneous resolution of acute perforations while maintaining vessel patency. Whereas iatrogenic perforations in the catheterization laboratory may thus be treated immediately at the site of their occurrence, rupture of pre-existing but potentially unknown coronary pathology frequently is associated with a diagnostic interval, giving rise to serious clinical events (i. e. myocardial infarction, cardiac tamponade, malign arrhythmias or sudden death). It may be warranted to advocate prophylactic treatment of ruptureprone coronary conditions even on incidential diagnosis. This can either be performed by cardiothoracic surgery or, in suitable cases, by interventional therapy. Implantation of coronary stent-grafts could prove to become the therapy of choice due to its technical facility, safety and the short length of hospital stay associated with it. Before general recommendations can be made, however, as to the extension of indication for these novel coronary devices, further clinical studies encompassing long-term clinical and angiographic follow-up are needed.
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Elsner, M., Zeiher, A.M. Perforation und Ruptur von Koronararterien. Herz 23, 311–318 (1998). https://doi.org/10.1007/BF03044364
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DOI: https://doi.org/10.1007/BF03044364