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Aktuelle Therapie des rupturierten abdominalen Aortenaneurysmas

Current therapy of ruptured abdominal aortic aneurysms

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Zusammenfassung

Das rupturierte abdominale Aortenaneurysma (rAAA) stellt einen Blutungsnotfall mit hämorrhagischem Schock und hoher perioperativer Letalität dar. Die präklinische Beurteilung erfordert eine rasche differenzialdiagnostische Abklärung, zielführende Diagnostik und eine sofortige Behandlung in spezialisierten Zentren. Die klassische operative Therapie besteht weiterhin als Standard in der offen chirurgischen Ausschaltung des Aneurysmas durch Implantation einer Rohr- oder Bifurkationsprothese. In den vergangenen Jahren wurde bei ausgewählten Patienten mit einem abdominalen Aortenaneurysma und geeigneter Aortenkonfiguration zunehmend die endovaskuläre Therapie durch Implantation eines aortobiiliakalen oder monoiliakalen Stentgrafts eingesetzt. Die endovaskuläre Therapie rupturierter abdominaler Aneurysmen ermöglicht bei sorgfältiger Patientenauswahl und detaillierter präoperativer Planung neue minimalinvasive Therapieoptionen auch bei Patienten mit schwerer Begleitmorbidität, obwohl die bisherigen Mitteilungen noch keine abschließende Beurteilung zulassen und Langzeitverläufe noch fehlen. Die perioperative Therapie besteht in der Behandlung des Mehrorganversagens nach hämorrhagischem Schock und Ischämie-Reperfusions-Syndrom durch Volumensubstitution, optimierter Gerinnungstherapie, der Aufrechterhaltung der Normothermie und der Beachtung einer möglichen intestinalen Ischämie und des abdominalen Kompartmentsyndroms.

Abstract

Ruptured abdominal aortic aneurysms (rAAA) still represent a vascular emergency with hemorrhagic shock and high perioperative mortality. Preclinical evaluation requires a rapid consideration of various differential diagnoses, straightforward diagnostic procedures and immediate treatment in specialized centres. Open surgical repair still remains the gold standard for treating ruptured abdominal aortic aneurysm. The mainstays of standard therapy consist of immediate bleeding control by open surgical aortic clamping or endovascular balloon occlusion, aneurysma exclusion by implantation of a tube or bifurcated alloplastic prosthesis. Endovascular aortic repair by implantation of bifurcated or aortomonoiliac stent grafts is increasingly being used in selected patients with suitable aortic configuration in an attempt to improve patient survival. For patients with ruptured abdominal aortic aneurysms endovascular aortic repair has become a new minimally invasive treatment option even in patients with severe comorbidities, although the data reported so far are not yet conclusive enough and long term results are missing. Perioperative therapy requires treatment of multiorgan failure following hemorrhagic shock and ischemia reperfusion damage by fluid administration, coagulation support, maintenance of normothermia and awareness of intestinal ischemia and abdominal compression syndrome.

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Authors and Affiliations

  1. Klinik für Viszeral-, Gefäß- und Thoraxchirurgie, Klinikum Harlaching, Städtisches Klinikum München GmbH, Sanatoriumsplatz 2, 81545, München, Deutschland

    R. Kopp, O. Hekeler & F. Gumpinger

  2. Chirurgische Klinik, Klinikum Großhadern, Ludwig-Maximilians Universität, München, Deutschland

    R. Kopp

  3. Klinik für internistische Akut- und Intensivmedizin, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Deutschland

    C. Peckelsen

  4. Klinik für Anästhesiologie und Intensivmedizin, Klinikum Harlaching, Städtisches Klinikum München GmbH, München, Deutschland

    W. Gogarten

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  1. R. Kopp
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  2. O. Hekeler
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  3. F. Gumpinger
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  4. C. Peckelsen
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  5. W. Gogarten
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Correspondence to R. Kopp.

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Kopp, R., Hekeler, O., Gumpinger, F. et al. Aktuelle Therapie des rupturierten abdominalen Aortenaneurysmas. Notfall Rettungsmed 12, 493–501 (2009). https://doi.org/10.1007/s10049-009-1189-y

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  • DOI: https://doi.org/10.1007/s10049-009-1189-y

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