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Rupturiertes abdominelles Aortenaneurysma

Versorgungsstrategie und Verfahrenswahl

Ruptured abdominal aortic aneurysm: treatment strategy and choice of procedure

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Zusammenfassung

Das rupturierte infrarenale abdominelle Aortenaneurysma stellt trotz operativ-technischer, anästhesiologischer sowie intensivmedizinischer Fortschritte nach wie vor einen gefäßchirurgischen Notfall mit sehr schlechter Prognose dar: 9 von 10 Patienten versterben bereits präklinisch, die Mortalitätsraten der operierten Patienten schwanken zwischen 35 und 70%. Verantwortlich für das schlechte postoperative Ergebnis sind in erster Linie die Komorbidität der meist älteren Patienten mit Dysfunktion relevanter Organsysteme und der simultan vorliegende hämorrhagische Schock. Klassischerweise wird das rupturierte Aortenaneurysma transperitoneal durch konventionellen Gefäßprothesenersatz chirurgisch versorgt. Seit ca. 10 Jahren besteht daneben die Möglichkeit, aortale Notfälle endovaskulär mittels Stentprothese zu versorgen. Dadurch wird zum einen das Operationstrauma einer Laparotomie vermieden, darüber hinaus entfällt die Aortenklemmung mit zusätzlichen pathophysiologischen Belastungen. Weiterer Vorteil ist die Durchführung des Eingriffs in Lokalanästhesie. Bei der Auswahl des geeigneten Operationsverfahrens müssen neben morphologischen Voraussetzungen, insbesondere infrastrukturelle Gegebenheiten berücksichtigt werden. Zur abschließenden Beurteilung des Stellenwerts der endovaskulären Therapie fehlen derzeit noch prospektiv randomisierte Studien.

Abstract

The ruptured infrarenal abdominal aortic aneurysm, despite technical advances in operating procedures, anesthesiology and intensive care medicine, continues to represent a life-threatening emergency with very bad prognosis. Nine out of ten patients pass away before reaching the hospital, mortality rates for patients treated operatively vary between 35 and 70%. The negative post-operative results are mainly due to the comorbidity of the mostly older patients with the deterioration of organ function and simultaneous hemorrhagic shock. For the past 50 years, the ruptured aortic aneurysm has been operated transperitoneally via conventional vascular prosthetic replacement. For the past ten years, there has also been the option of treating aortic emergencies endovascularly by means of a stent prosthesis (eEVAR; emergency endovascular aortic repair). By implanting an endograft system, the operative trauma of a laparotomy is dispensed with, and aortic clamping, with the accompanying pathophysiologic stresses is also avoided. Another advantage is that the operation can be performed under local anesthesia. When selecting an operative procedure, in addition to morphologic conditions, a suitable infrastructural environment needs to be assured. There are no clear answers in the final analysis of the relative value of eEVAR. It is both necessary and ethically justifiable that prospective randomized studies be performed to establish a preference.

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  1. Abteilung für Gefäßchirurgie, vaskuläre und endovaskuläre Chirurgie, Chirurgische Universitätsklinik Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    S. Ockert, D. Böckler, J. Allenberg & H. Schumacher

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  1. S. Ockert
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  2. D. Böckler
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  3. J. Allenberg
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  4. H. Schumacher
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Correspondence to S. Ockert.

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Ockert, S., Böckler, D., Allenberg, J. et al. Rupturiertes abdominelles Aortenaneurysma. Gefässchirurgie 12, 379–391 (2007). https://doi.org/10.1007/s00772-007-0542-z

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