Endovaskuläre Therapie des Aortenbogens

Endovascular treatment of aortic arch pathologies

Zusammenfassung

Hintergrund

Für Pathologien des Aortenbogens gilt bisher die offene Chirurgie als „Goldstandard“. Trotz technischer, anästhesiologischer und chirurgischer Entwicklungen, wird für die offenen Verfahren ein hypothermer Kreislaufstillstand mit hohem perioperativem Risiko notwendig und ist damit für multimorbide Patienten nicht anwendbar. Die endovaskulären Techniken haben in den letzten 20 Jahren Einzug in die Versorgung von Aortenpathologien, auch der thorakalen Aorta, gehalten. Während für Pathologien der deszendierenden Aorta die thorakale endovaskuläre Stentversorgung mittlerweile zum Standard geworden ist, gewinnt diese Technik insbesondere für Notfälle wie bei symptomatischen und rupturierten Aneurysmen und bei multimorbiden Patienten immer mehr Anwendung im Bereich des gesamten Aortenbogens. Aufgrund der abgehenden supraaortalen Gefäße mit nur minimaler Ischämietoleranz, Krümmung der Aorta sowie Nähe zum kardialen Auswurftrakt unterliegt die endovaskuläre Versorgung des Aortenbogens großen technischen Herausforderungen.

Fragestellung

Welche Therapieoptionen bieten die endovaskulären Techniken für den individuellen Patienten?

Ergebnisse

Zu den endovaskulären Therapieoptionen des Aortenbogens zählen kombiniert offen und endovaskuläre Hybridverfahren und endovaskuläre Techniken wie die fenestrierten und gebranchten Stentprothesen, die Chimney-Graft-Technik und die In-situ-Fenestrierung. Die individuell angefertigten fenestrierten und gebranchten Stentprothesen gelten als gute Therapiealternative für Patienten mit hohem perioperativen Risiko für eine offen-chirurgische Versorgung und könnten sich in Zukunft zur Therapie der Wahl entwickeln. Die Chimney-Graft-Technik und In-situ-Fenestrierung sind als „Bail-out“-Strategien für die endovaskuläre Versorgung von Aortenpathologien geeignet.

Schlussfolgerung

Die endovaskulären Techniken unterliegen schnellen Entwicklungen und Verbesserungen und werden in spezialisierten Zentren bereits regelhaft als alternative Therapieoption für Hochrisikopatienten mit geeigneter Anatomie angewandt.

Abstract

Background

Open surgical treatment represents the gold standard for pathologies of the aortic arch. Despite surgical, anesthesiological and technical developments of open surgery, hypothermic circulatory arrest with a high perioperative risk is still necessary and cannot therefore be used for multimorbid patients. Endovascular techniques have made impressive developments over the last 20 years and are the treatment of choice for pathologies of the descending aorta. In emergency situations, such as ruptured or symptomatic aneurysms and in multimorbid patients, endovascular techniques are currently becoming a treatment alternative for lesions of the aortic arch. Due to the complexity of the aortic arch with its supra-aortic vessels, angulation and proximity to the heart, endovascular treatment is a challenging task.

Objective

Which therapy options are offered by endovascular techniques for individual patients?

Results

Endovascular treatment options for the aortic arch include hybrid debranching procedures and endovascular techniques, such as fenestrated and branched stent grafts, chimney graft procedures and in situ fenestration. Customized fenestrated and branched stent grafts are considered to be a good alternative treatment for patients unfit for open surgery and could become the treatment of choice in the future. Chimney grafts and in situ fenestration are suitable as valuable bail-out strategies for aortic arch pathologies.

Conclusion

Endovascular techniques are rapidly developing and improving and have currently become a valid alternative treatment in specialized centers for high risk patients with aortic arch pathologies.

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Correspondence to Dr. F. Heidemann.

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Interessenkonflikt

F. Heidemann, F. Rohlffs und C.-A. Behrendt geben an, dass kein Interessenkonflikt besteht. N. Tsilimparis: Proktor für Cook Medical. E.S. Debus: Forschungsförderung von Cook Medical. T. Kölbel: Proktor und wissenschaftlicher Sprecher für Cook Medical; erhält Forschungsförderung und Royalties von Cook Medical. A. Larena-Avellaneda: Honorare für Vortragstätigkeiten, Firma Cook

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Heidemann, F., Tsilimparis, N., Rohlffs, F. et al. Endovaskuläre Therapie des Aortenbogens. Gefässchirurgie 21, 217–223 (2016). https://doi.org/10.1007/s00772-016-0162-6

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Schlüsselwörter

  • Aorta
  • endovaskuläre Technik
  • Stentprothese
  • Chimney-Graft
  • In-situ-Fenestrierung

Keywords

  • Aorta
  • Endovascular technique
  • Stent graft
  • Chimney graft
  • In situ fenestration