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Offen-chirurgische Therapie thorakoabdomineller Aortenaneurysmen und chronisch expandierender Aortendissektionen

Analyse perioperativer Prognosefaktoren

Open surgical therapy of thoracoabdominal aortic aneurysms and chronic expanding aortic dissections

Analysis of perioperative prognostic factors

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Zusammenfassung

Studienziel

Ziel der Studie war es, perioperative Prognosefaktoren für das Kurz- und Langzeitüberleben nach offen-chirurgischer Therapie thorakoabdomineller Aortenaneurysmen (TAAA) und chronisch expandierender Aortendissektionen (CEAD) zu identifizieren.

Patienten und Methoden

Zwischen März 1993 und Dezember 2005 wurden 92 Patienten in unserer Klinik elektiv an einem TAAA oder einer CEAD Typ Stanford B offen-chirurgisch operiert. Eine passive distale Aortenperfusion während der Aortenausklemmung kam bei 36 Patienten (39%) zum Einsatz. Die Akten und die bildgebenden Untersuchungen aller Patienten wurden retrospektiv analysiert. Die Nachuntersuchungen im Rahmen der Verlaufskontrolle beinhalteten Anamneseerhebung, klinische Untersuchung, transabdominelle Sonographie und kontrastmittelgestützte CT- oder MR-Angiographie. Das mediane Follow-up betrug 40 Monate (1–139).

Ergebnisse

Für das Gesamtkollektiv betrug die intraoperative, 30-Tage- und Krankenhausmortalitätsrate 2%, 8% und 12%. Die 5-Jahres-Überlebenswahrscheinlichkeit betrug 70%. 43% aller Todesursachen waren kardial bedingt. Die Paraplegierate betrug 10%, die Rate einer neu aufgetreten dauerhaften dialysepflichtigen Niereninsuffizienz 3%. Bei 21% der Patienten bestand die Notwendigkeit zu einer Revision. Es konnten als unabhängige Prädiktoren für die 30-Tage-Mortaltät die Notwendigkeit einer Revision (OR: 8,465; CI: 0,802–89,318; p=0,024) und ein postoperativer Transaminasenanstieg (OR: 1,009; CI: 1,002–1,017; p=0,017) identifiziert werden. Für das Langzeitüberleben wurden als unabhängige negative Prognosefaktoren das Vorbestehen einer PAVK (OR: 4,41; CI:1,672–11,611; p=0,003), das Auftreten einer intraoperativen Komplikation wie disseminierte intravasale Gerinnung und Asystolie (OR: 4,28; CI: 1,128–16,267; p=0,033), ein postoperativer Bilirubinanstieg >2,5 mg/dl (OR: 1,06; CI: 1,009–1,112; p=0,019) sowie eine postoperative Nachbeatmungszeit >7 Tage (OR: 7,79; CI: 2,499–24,246; p<0,0001) identifiziert.

Schlussfolgerung

Postoperativ erhöhte Transaminasen sind ein negativer Prognosefaktor. Ein standardisierter Einsatz aktiver Shuntsysteme für die Organperfusion erscheint sinnvoll.

Abstract

Aim of the stydy

The aim of the study was to investigate perioperative prognostic factors and long-term outcome following conventional open repair (COR) of thoracoabdominal aortic aneurysms (TAAA) and chronic expanding aortic dissections (CEAD).

Patients and methods

Between March 1993 and December 2005, 92 patients underwent elective COR for TAAA or CEAD in our institution. Passive distal aortic perfusion during cross-clamping was used in 36 patients (39%). Medical records and imaging studies of all patients were reviewed. Follow-up included history, physical examination and CT or MR angiography. Median follow-up was 40 months (range 1–139 months).

Results

Intraoperative, 30-day and in-hospital mortality rates were 2%, 8% and 12%, respectively. The estimated survival rate after 5 years was 70% and 43% of all deaths were cardiac related. The paraplegia rate was 10%, the rate of patients developing chronic renal failure requiring hemodialysis was 3% and 21% of patients required surgical revision. In multivariate analyses the need for surgical revision (OR: 8.465; CI: 0.802–89.318; p=0.024) and postoperative elevated serum transaminase values (OR: 1.009; CI: 1.002–1.017; p=0.017) independently predicted 30-day mortality. Peripheral arterial disease (OR: 4.41; CI:1.672–11.611; p=0.003), intraoperative complications such as disseminated intravasal coagulation and asystole (OR: 4.28; CI: 1.128–16.267; p=0.033), postoperative elevated bilirubin values >2.5 mg/dl (OR: 1.06; CI: 1.009–1.112; p=0.019), and postoperative ventilation >7 days (OR: 7.79; CI: 2.499–24.246; p<0,0001) independently predicted long-term mortality.

Conclusion

Postoperative elevated liver values represent negative prognostic factors and may indicate a more standardized use of active shunt systems for organ perfusion.

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Authors and Affiliations

  1. Klinik für Gefäßchirurgie, Universitätsklinikum, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    D. Kotelis, M. Riemensperger, A. Hyhlik-Dürr & D. Böckler

  2. Institut für medizinische Biometrie und Informatik, Universitätsklinikum, Heidelberg, Deutschland

    E. Jenetzky

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  1. D. Kotelis
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  2. M. Riemensperger
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  3. E. Jenetzky
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  4. A. Hyhlik-Dürr
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  5. D. Böckler
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Correspondence to D. Kotelis.

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Kotelis, D., Riemensperger, M., Jenetzky, E. et al. Offen-chirurgische Therapie thorakoabdomineller Aortenaneurysmen und chronisch expandierender Aortendissektionen. Chirurg 82, 661–669 (2011). https://doi.org/10.1007/s00104-010-1989-0

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