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Endovaskuläre Versorgung: der komplizierte Aneurysmahals

Morphologische Definition, Auswirkungen auf das Langzeitergebnis und Therapieoptionen

Endovascular aortic repair: the hostile aneurysm neck

Morphologic definition, impact on long-term outcome, and treatment options

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Zusammenfassung

Definition

Der komplizierte Hals wird durch verschiedene anatomische Gegebenheiten definiert, welche eine für die endovaskuläre Versorgung („endovascular aneurysm repair“, EVAR) unvorteilhafte Morphologie des proximalen Aneurysmahalses infrarenaler Aortenaneurysmen beschreiben: Länge der proximalen Landungszone ≤ 15 mm, Angulierung des Aortenhalses > 60°, konischer Aortenhals, Durchmesser des Aortenhalses > 32 mm sowie zirkumferente Kalzifizierungen bzw. zirkumferenter Thrombussaum.

Auswirkungen auf das Therapieergebnis

Diese morphologischen Parameter sind im Rahmen einer Standard-EVAR-Versorgung nicht nur mit einer höheren perioperativen technischen Misserfolgsrate (primäre Typ-1-Endoleckage), sondern auch mit schlechteren Langzeitergebnissen (sekundäre Typ-1-Endoleckage) und damit einer höheren Reinterventionsrate assoziiert, sodass eine reine EVAR in diesen Fällen nur wenigen Ausnahmen vorbehalten sein sollte.

Therapieoptionen

Durch die rasante Entwicklung der endovaskulären Techniken im letzten Jahrzehnt steht heute neben der konventionell offenen Operation, welche in vielen Fällen immer noch die Standardmethode darstellt und gerade eine Renaissance erfährt, eine Vielzahl endovaskulärer Therapieverfahren für Aneurysmen mit komplizierten Hälsen sowohl für die elektive Behandlung als auch in der Notfallversorgung zur Verfügung: fenestrierte Stentprothese (FEVAR) als elektive Methode der ersten Wahl, EVAR mit Chimneys (ChEVAR), EVAR mit Verschraubung durch Endostapler („endosuture aneurysm repair“, ESAR). Dennoch ist eine wichtige Alternative das konservative Vorgehen, welches unter Einbeziehung des Patientenwunsches und einer sorgfältigen Nutzen-Risiko-Abwägung eine sinnvolle Option sein kann.

Abstract

Definition

A hostile neck is defined by various anatomical conditions that describe a morphology of the proximal aneurysmal neck of infrarenal aortic aneurysms that is unfavorable for endovascular treatment (endovascular aortic repair, EVAR): proximal landing zone length ≤ 15 mm, angulation of the aortic neck > 60°, conical aortic neck, diameter of the aortic neck > 32 mm, and circumferential calcification/thrombus.

Effects on outcome

These morphological parameters are not only associated with a higher perioperative technical failure rate (primary type 1 endoleak) but also with poorer long-term results (secondary type 1 endoleak) and thus a higher reintervention rate in standard EVAR, so that standard EVAR should be reserved for a few exceptions in these cases.

Treatment options

Due to the rapid development of endovascular techniques in the last decade, we now have a variety of endovascular options for aneurysms with hostile necks, for both elective treatment and emergency care, in addition to conventional open surgery, which is still the standard method in many cases and is currently undergoing a renaissance: fenestrated endovascular aortic repair (FEVAR) as the method of first choice in the elective setting, EVAR with chimneys (ChEVAR), endosuture aneurysm repair (ESAR). An important option is the conservative approach, which can be a reasonable choice if the patient’s preference is taken into account and a careful risk–benefit assessment is performed.

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Abbreviations

ChEVAR:

Chimney endovascular aneurysm repair

ESAR:

Endosuture aneurysm repair

EVAR:

Endovascular aneurysm repair

FEVAR:

Fenestrated endovascular aneurysm repair

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Authors and Affiliations

  1. Klinik für Diagnostische und Interventionelle Radiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70195, Stuttgart, Deutschland

    Tobias Trabold EBIR-ES, Götz M. Richter & Rebekka Rosner

  2. Klinik für Gefäßchirurgie, Endovaskuläre Chirurgie und Transplantationschirurgie, Klinikum Stuttgart, Stuttgart, Deutschland

    Philipp Geisbüsch

Authors
  1. Tobias Trabold EBIR-ES
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  2. Götz M. Richter
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  4. Philipp Geisbüsch
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Correspondence to Tobias Trabold EBIR-ES.

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Interessenkonflikt

P. Geisbüsch: Consultant für die Medtronic GmbH. T. Trabold, G.M. Richter und R. Rosner geben an, dass kein Interessenkonflikt besteht.

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

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Trabold, T., Richter, G.M., Rosner, R. et al. Endovaskuläre Versorgung: der komplizierte Aneurysmahals. Radiologie 62, 563–569 (2022). https://doi.org/10.1007/s00117-022-01018-2

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