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Was haben wir aus prospektiv randomisierten Studien über Aortenaneurysmen gelernt?

Welche Fragen stehen noch offen?

What have we learned about aortic aneurysms from prospective randomized trials?

Which questions are still open?

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Zusammenfassung

Das Bauchaortenaneurysma (BAA) ist eine komplexe Erkrankung, deren Behandlung in den letzten 50 Jahren einen deutlichen Wandel erfahren hat. Mit der Verfeinerung der chirurgischen Techniken, der anästhesiologischen Abläufe und des perioperativen Monitorings konnte die Mortalität erheblich gesenkt werden. Zusätzlich, nach Initiierung der endovaskulären Techniken, hat diese Methode in den letzten Jahrzehnten eine starke Verbreitung erfahren und gilt nun als ein Hauptpfeiler zur Behandlung des BAA. Neben der Verbreitung und Verfeinerung der endovaskulären Techniken zeichnet sich auch eine deutliche Zunahme der wissenschaftlichen Auseinandersetzung mit der aneurysmatischen Erkrankung der abdominellen Aorta und deren Behandlungsoptionen ab. Viele randomisierte kontrollierte Studien (RCTs) sind durchgeführt worden, um verschiedene Aspekte des Managements von BAA zu erleuchten. Insbesondere 4 RCTs versuchten, die Rolle des Screenings auf BAA in der allgemeinen Bevölkerung zu untersuchen. Vier weitere RCTs sind der Frage nach der optimalen Behandlungsmethode für kleine BAA nachgegangen. Auf die Behandlung von symptomfreien BAA >5,5 cm konzentrierten sich 5 RCTs. 3 RCTs haben den potenziellen Nutzen der endovaskulären Methode für das Management von Patienten mit rupturierten BAA untersucht. RCTs sind jedoch aufwendige Arbeiten und können nicht alle Fragen zu neuen Technologien beantworten. Viele klinische Situationen von Patienten mit BAA bleiben in den RCTs unberücksichtigt. Die Daten und Ergebnisse dieser RCTs über das Management von BAA sowie einige der offenen Fragen werden hier diskutiert.

Abstract

Abdominal aortic aneurysms (AAA) are complex diseases and the management has significantly changed over the last 50 years. With the evolution of surgical techniques, anesthetic procedures and perioperative monitoring, the mortality has nowadays considerably declined. After initiation of the endovascular techniques this method greatly expanded over the next decades and has now become a mainstay in the treatment of AAA. This evolution in the management of AAA is accompanied by a significant increase in the quantity of scientific literature concerning this entity. A handful of randomized controlled trials (RCTs) were conducted in order to clarify the various aspects of the management of AAA. In particular, four RCTs tried to investigate the role of screening for AAA in the general population, whereas four further RCTs tried to identify the optimal treatment modality for small AAA. Great interest has also been raised with respect to the management of asymptomatic AAA >5.5 cm, since five RCTs were performed. Finally, three RCTs investigated the potential benefit of the endovascular method on the management of patients with ruptured AAA; however, RCTs are major undertakings and cannot answer all of the questions arising about new technologies. Furthermore, many clinical situations of patients with AAAs have not been the subject of RCTs, although patient care needs to be delivered and decisions have to be made in these situations. The data and conclusions of these RCTs on the management of AAA as well as some of the unanswered questions are reviewed and discussed in this article.

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  1. Klinik und Poliklinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum, Universität zu Köln, Kerpener Straße 62, 50937, Köln, Deutschland

    S. N. Mylonas FEBVS &  J. S. Brunkwall FEBVS

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Correspondence to S. N. Mylonas FEBVS.

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S.N. Mylonas und J.S. Brunkwall geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren. Für die im Beitrag zitierten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Mylonas, S.N., Brunkwall, J.S. Was haben wir aus prospektiv randomisierten Studien über Aortenaneurysmen gelernt?. Gefässchirurgie 23, 331–339 (2018). https://doi.org/10.1007/s00772-018-0423-7

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