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Nieren-Prophylaxe bei thorakaler Aortenchirurgie

Renal protection in thoracic aortic surgery

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Clinical Research in Cardiology Supplements Aims and scope

Summary

The gold standard for treatment thoracic, thoracoabdominal and suprarenal aortic aneurysms is still surgical. Throughout the past 20 years, total mortality and morbidity of such operations has markedly decreased. However, the occurrence of postoperative acute renal failure (ARF) still represents a significant factor influencing 30 day and long-term outcome. Strategies to prevent ARF may be classified into preoperative, intraoperative and postoperative measures. Preoperatively it is pre-existing reduced renal function that mainly determines the risk of postoperative ARF and the requirement for dialysis. Adjustment of drug therapy and adequate fluid balance are the mainstay of preoperative risk reduction. Intraoperatively the prevention or amelioration of renal ischemia is essential. Various perfusion methods, regional or global hypothermia of at least 33 °C and pharmacological measures (fenoldopam, mannitol) to improve perfusion of the renal parenchyma are employed. Surgical techniques aim to prevent microembolization of atheroma and cholesterol during handling and perfusion. Aggressive endarterectomy of stenosed renal arteries and the avoidance of bypass procedures or direct reinsertions into the prosthetic graft giving preference to island patch reinsertion of all four visceral/renal arteries are performed. Supportive intraand postoperative measures such as adequate fluid replacement, sufficient cardiac output and luxurious oxygen supply are essential. Adopting these methods post operative ARF may successfully be reduced to 2–13%.

Zusammenfassung

Die operative Behandlung thorakaler, thorakoabdomineller und suprarenaler Aortenaneurysmen stellt weiterhin den Goldstandard der Therapie dar. Dabei hat sich über die vergangenen 20 Jahre eine deutliche Senkung der Mortalität und Morbidität eingestellt, wobei das postoperative akute Nierenversagen einen unverändert hohen Stellenwert sowohl bezüglich der 30-Tage-Mortalität als auch des Langzeitüberlebens einnimmt. Strategien zur Prävention des akuten Nierenversagens lassen sich in präoperative, intraoperative und postoperative Maßnahmen einteilen. Präoperativ spielt vor allem die vorbestehende chronische Niereninsuffizienz die wesentliche Rolle für ein postoperatives akutes Nierenversagen oder eine Dialysepflicht. Vor einer Operation sollte eine Optimierung von Flüssigkeitshaushalt und präoperativer Medikation erfolgen. Intraoperativ konzentrieren sich die Maßnahmen auf die Vermeidung prärenaler Faktoren inklusive der direkten Nierenischämie mit verschiedenen Perfusionsverfahren, ferner die Kühlung der Nieren entweder kontinuierlich oder intermittierend mindestens auf 33 °C sowie die pharmakologische Optimierung der Nierenperfusion mit Mannitol und Fenoldopam. Chirurgisch technische Aspekte betreffen vor allem die Vermeidung von Embolien in die Nierenarterien, die konsequente Desobliteration stenosierter Nierenarterien und die Vermeidung von Nierenarterienbypässen zugunsten einer Inselreinseration, soweit möglich. Unterstützende Maßnahmen sind intra- und postoperativ ausreichende Flüssigkeitszufuhr, die Aufrechterhaltung eines adäquaten Herzzeitvolumens sowie einer ausreichenden Diurese und die suffiziente Oxygenierung. Unter Beachtung der genannten Maßnahmen lässt sich die Inzidenz der Niereninsuffizienz auf zwischen 2 und 13% begrenzen.

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Authors and Affiliations

  1. Klinik für Thorax-, Herz- und Gefäßchirurgie, Medizinische Hochschule Hannover, Carl-Neuberg-Strasse 1, 30625, Hannover, Germany

    A. M. Pichlmaier &  O. E. Teebken

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  1. A. M. Pichlmaier
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  2. O. E. Teebken
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Correspondence to A. M. Pichlmaier.

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Pichlmaier, A.M., Teebken, O.E. Nieren-Prophylaxe bei thorakaler Aortenchirurgie. Clin Res Cardiol Suppl 2 (Suppl 1), S60–S66 (2007). https://doi.org/10.1007/s11789-006-0040-y

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  • DOI: https://doi.org/10.1007/s11789-006-0040-y

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