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Akute und chronisch-expandierende Aortendissektion Typ Stanford B—Verändert die endovaskuläre Therapie die Indikationsstellung?

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Zusammenfassung

Fragestellung

Die medikamentös-konservative Therapie stellt derzeit den "golden standard" im Management der akuten unkomplizierten Aortendissektion Typ Stanford B dar. Die Verfügbarkeit und geringere Invasivität von endoluminalen Stentprothesen hat potenziell das Spektrum der Therapieoptionen erweitert. Ist es zum gegenwärtigen Zeitpunkt gerechtfertigt, die Indikationsstellung auszuweiten und prophylaktisch die unkomplizierte Typ-B-Dissektion endovaskulär zu versorgen, um eine spätere chronische Expansion zu verhindern? Anhand der Erfahrungen mit 23 Patienten werden die Indikationsstellung und die ersten Ergebnisse diskutiert und zu dem vermeintlichen Wandel in der Indikationsstellung Stellung genommen.

Patienten und Methodik

Zwischen April 2000 und März 2003 wurden 23 Patienten mit akuter, komplizierter oder chronisch-expandierender Aortendissektion Typ Stanford B durch Implantation einer thorakalen Endoprothese versorgt. 10 dieser Operationen (53%) wurden notfallmäßig wegen viszeraler Panischämie oder Ruptur durchgeführt. Der mittlere Nachbeobachtungszeitraum dieser Patientengruppe (18 Männer und 5 Frauen, Durchschnittsalter 46 Jahre [36–80 Jahre]) beträgt 18 Monate (1–34 Monate).

Ergebnisse

Die Implantation erfolgte in 22 von 23 Fällen erfolgreich. Die Paraplegierate beträgt 0, eine Endoleckage vom Typ I ist trotz proximalem Cuff persistent und muss sekundär konvertiert werden. Eine komplette Thrombosierung des Falschkanals wurde in 10 von 19 Fällen beobachtet (53%). Bei 8 Patienten kam es zu einer Teilthrombosierung mit einer Restitutio der Viszeralperfusion und einer Regression des Falschkanals. 2 Patienten zeigten nach endoluminalem Entryverschluss eine komplette Schrumpfung des Falschkanals, jedoch eine chronische Expansion im nicht versorgten viszeralen Aortensegment, das bereits initial einen Durchmesser von 4 cm aufwies. Die 30 Tage-Mortalität beträgt bei elektiven Eingriffen 0% und in Notfällen 20%. Ein Patient verstarb an Multiorganversagen, ein zweiter an einer Ruptur.

Schlussfolgerungen

Obwohl die endoluminalen Entryausschaltung bei akuter bzw. symptomatischer B-Dissektion ein vielversprechendes Konzept darstellt, sind Langzeitergebnisse (Expansion des Viszeralsegments, Ruptur, Materialermüdung und Konversionsrate) im Rahmen einer prospektiven Evaluierung notwendig, um den Stellenwert einer prophylaktischen endovaskulären Therapie der akuten unkomplizierten Dissektion zu evaluieren.

Abstract

Introduction

At present, drug therapy and conservative treatment represent the gold standard in the management of acute uncomplicated Stanford type B aortic dissection. Availability and low invasive impact of endoluminal stent grafts have potentially created a wider range of therapy options. Have these circumstances led to a change in indication?

Material and methods

Between April 2000 and March 2003, 23 of our patients had a type B dissection. Ten interventions (53%) were emergency cases. The median follow-up period in this patient population (18 men and 5 women, median age: 46 years, range: 36–80 years) amounted to 18 months (1–34 months). Follow-up checks were done by conventional thoracic X-ray, CT scan, and magnetic resonance angiography. Indication (multiple factors) for intervention was seen in symptomatic so-called "true lumen collapse" (n=12), chronic expansion (CEAD) >6 cm (n=10), rupture (n=1), and visceral ischemia (n=7). In four cases we implanted an iliac Dacron conduit as a temporary vessel access. The endograft deployment was performed in adenosine-induced cardiac arrest (n=19). We used 22 Excluder® (WL GORE) and 1 Endofit® (Endomed, Inc. ) endografts. "Oversizing" of 15–20% was done in all cases.

Results

Implantation was successful in 22 out of 23 cases. We had no patient who suffered paraplegia and one patient with a persistent type 1 endoleak despite proximal cuff. Complete thrombosis of the false lumen was observed in 10 out of 19 cases (53%). An endoluminal entry occlusion led to chronic expansion in the visceral aortic segment in two patients. The 30-day mortality rate amounts to 0% in elective interventions, and to 20% in emergency interventions (two out of ten patients). One patient died from multiple organ failure, another patient due to a rupture. Death in three more patients during the follow-up period was caused by cardiopulmonary diseases.

Conclusions

The concept of endoluminal entry exclusion in acute or symptomatic type B dissections is promising. However, long-term results (i.e., expansion of the visceral segment, rupture, material fatigue, and conversion rate) collected in a prospective evaluation of endovascular treatment are necessary to assess the importance of preventive endovascular therapy of the acute uncomplicated dissection.

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Authors and Affiliations

  1. Abeilung für Gefäßchirurgie, Chirurgische Universitätsklinik Heidelberg

    D. Böckler, H. Schumacher, S. Ockert, M. Schwarzbach, K. Klemm & J.-R. Allenberg

  2. Abteilung für Radiodiagnostik, Ruprecht-Karls-Universität Heidelberg

    J. Hansmann

  3. Klinik für Anästhesiologie, Ruprecht-Karls-Universität Heidelberg

    H. Bardenheuer

  4. Ruprecht-Karls-Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg

    D. Böckler

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  1. D. Böckler
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Correspondence to D. Böckler.

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Böckler, D., Schumacher, H., Ockert, S. et al. Akute und chronisch-expandierende Aortendissektion Typ Stanford B—Verändert die endovaskuläre Therapie die Indikationsstellung?. Gefässchirurgie 8, 192–199 (2003). https://doi.org/10.1007/s00772-003-0283-6

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