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Zentralbl Chir 2021; 146(05): 470-478
DOI: 10.1055/a-1562-2770
Übersicht

Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?

Open thoracic and thoracoabdominal aortic repair vs. f/bTEVAR – complementary or competitive?
Albert Busch
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
Steffen Wolk
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
Brigitta Lutz
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
Carolin Zimmermann
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
Miroslav Ankudinov
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
David Klenk
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
Florian Ehehalt
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
Thomas Rössel
2   Department of Anesthesiology and Intensive Care Medicine, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
Stefan Ludwig
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
,
Christian Reeps
1   Department for Visceral, thoracic and vascular surgery, University Hospital and Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
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Erratum: Offener thorakaler und thorakoabdominaler Aortenersatz vs. f/b(T)EVAR – komplementär oder kompetitiv?Zentralbl Chir 2021; 146(05): e7-e7
DOI: 10.1055/a-1691-2608

Zusammenfassung

Der offen-chirurgische thorakale und thorakoabdominelle Aortenersatz (open repair, OR) bei Aneurysmen oder Dissektionen hat in der aktuellen Versorgungsrealität im Vergleich zur endovaskulären Versorgung mit einfachen und speziellen Stentprothesen (fenestrated/branched [thoracic] endovascular aortic repair, f/b[T]EVAR) eine deutlich untergeordnete Rolle. Zudem besteht die Notwendigkeit einer hohen technischen Expertise und eines umfangreichen operativen Settings, um ein OR sicher anbieten zu können.

Zu Reduktion der spezifischen Komplikationen, wie z. B. perioperative Mortalität, permanente Dialysepflichtigkeit, spinale Ischämie, Schlaganfall oder Mesenterialischämie, ist ein hohes Maß an intraoperativer Protektion, z. B. mittels Liquordrainage, Point-of-Care-Gerinnungstherapie, distaler oder selektiver Aortenperfusion im Sinne eines temporären Linksherzbypasses und sequenziellem Clamping der Aorta erforderlich. Trotz der Dominanz der endovaskulären Therapie ist diese Expertise aber weiterhin nötig, um spezifische Indikationen, wie beispielsweise junges Patientenalter oder Bindegewebserkrankungen bzw. Protheseninfektionen, sicher versorgen zu können. Zusätzlich ist nicht jedes Aneurysma oder jede Dissektion anatomisch langfristig sicher mit einer endovaskulären Behandlung zu therapieren.

Die aktuelle Evidenzlage sieht einen geringen, meist nicht statistisch signifikanten Vorteil von TEVAR und f/bEVAR versus OR bei den wichtigsten kurz- und mittelfristigen Ergebnisparametern, bei deutlich geringerer Invasivität und verkürzter Krankenhausliegedauer. Im langfristigen Verlauf sind die Ergebnisse bezüglich Gesamtüberleben und Re-Interventionsraten bzw. sekundärer Komplikationen bei OR deutlich besser.

Der offene thorakoabdominelle Aortenersatz ist also nach wie vor mehr als ein exklusives Hobby, sondern vielmehr eine absolute Notwendigkeit im Gesamtspektrum der aortalen Chirurgie, dessen Bedeutung in den nächsten Jahren mutmaßlich wieder zunimmt.

Abstract

The classical approach of open repair (OR) for thoracic and thoracoabdominal aortic pathologies, including aneurysms and dissection, has been outnumbered by the use of fenestrated/branched (thoracic) endovascular aortic repair (f/b[T]EVAR) in recent years. Providing OR for complex cases in an aortic service requires a dedicated surgical setup and a huge body of expertise in this particular field.

In order to reduce specific complications, such as perioperative mortality, kidney failure, spinal cord ischemia, stroke or bowel ischemia, it is necessary to apply cerebrospinal-spinal fluid drainage, point-of-care coagulation therapy, distal and retrograde aortic perfusion and sequential clamping. Despite the predominance of endovascular solutions, the specific OR expertise is still needed for specific indications, such as young patients, connective tissue disorder or aortic graft infections.

Currently, the short and mid term results for f/b(T)EVAR outweigh those for OR, including the shorter hospital stay and less invasive procedures. However, OR provides better long-term results for overall mortality, re-intervention rates and secondary complications.

In conclusion, in our opinion OR is a service that is still necessary for dedicated aortic centres, but will most likely become more frequent again in the years to come.

Schlüsselwörter

Aortenaneurysma - open repair - thorako-abdominale Aorta - Bindegewebserkrankung - spinale Ischämie

Keywords

aortic aneurysm - open repair - thoracoabdominal aorta - connective tissue disease - spinal cord ischemia


Publication History

Received: 11 June 2021

Accepted after revision: 28 July 2021

Article published online:
19 October 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Geisbusch S, Kuehnl A, Salvermoser M. et al. Editor’s Choice – Hospital Incidence, Treatment, and In Hospital Mortality Following Open and Endovascular Surgery for Thoraco-abdominal Aortic Aneurysms in Germany from 2005 to 2014: Secondary Data Analysis of the Nationwide German DRG Microdata. Eur J Vasc Endovasc Surg 2019; 57: 488-498
    CrossrefPubMedSearch in Google Scholar
  • 2 Nordon IM, Hinchliffe RJ, Loftus IM. et al. Pathophysiology and epidemiology of abdominal aortic aneurysms. Nat Rev Cardiol 2011; 8: 92-102
    CrossrefPubMedSearch in Google Scholar
  • 3 Crawford ES, Coselli JS. Thoracoabdominal aneurysm surgery. Semin Thorac Cardiovasc Surg 1991; 3: 300-322
    CrossrefPubMedSearch in Google Scholar
  • 4 Gaudino M, Girardi LN, Rahouma M. et al. Editor’s Choice – Aortic Re-operation After Replacement of the Proximal Aorta: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2018; 56: 515-523
    CrossrefPubMedSearch in Google Scholar
  • 5 Jonker FH, Trimarchi S, Rampoldi V. et al. Aortic expansion after acute type B aortic dissection. Ann Thorac Surg 2012; 94: 1223-1229
    CrossrefPubMedSearch in Google Scholar
  • 6 Orozco-Sevilla V, Weldon SA, Coselli JS. Hybrid thoracoabdominal aortic aneurysm repair: is the future here?. J Vis Surg 2018; 4: 61
    CrossrefPubMedSearch in Google Scholar
  • 7 Aftab M, Songdechakraiwut T, Green SY. et al. Contemporary outcomes of open thoracoabdominal aortic aneurysm repair in octogenarians. J Thorac Cardiovasc Surg 2015; 149 (Suppl. 02) S134-S141
    CrossrefPubMedSearch in Google Scholar
  • 8 Khan FM, Naik A, Hameed I. et al. Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: A Meta-Analysis. Ann Thorac Surg 2020; 110: 1941-1949
    CrossrefPubMedSearch in Google Scholar
  • 9 Coselli JS, LeMaire SA, Preventza O. et al. Outcomes of 3309 thoracoabdominal aortic aneurysm repairs. J Thorac Cardiovasc Surg 2016; 151: 1323-1337
    CrossrefPubMedSearch in Google Scholar
  • 10 Estrera AL, Sandhu HK, Charlton-Ouw KM. et al. A Quarter Century of Organ Protection in Open Thoracoabdominal Repair. Ann Surg 2015; 262: 660-668
    CrossrefPubMedSearch in Google Scholar
  • 11 Simon F, Wagenhauser MU, Busch A. et al. Arteriogenesis of the Spinal Cord-The Network Challenge. Cells 2020; 9: 501
    CrossrefPubMedSearch in Google Scholar
  • 12 von Aspern K, Haunschild J, Borger MA. et al. Anatomical description of the intraspinal collateral network: bringing the concept full circle-is the devil in the details?. Eur J Cardiothorac Surg 2021; 59: 144-146
    CrossrefPubMedSearch in Google Scholar
  • 13 Mousa AY, Morcos R, Broce M. et al. New Preoperative Spinal Cord Ischemia Risk Stratification Model for Patients Undergoing Thoracic Endovascular Aortic Repair. Vasc Endovascular Surg 2020; 54: 487-496
    CrossrefPubMedSearch in Google Scholar
  • 14 Jayia P, Constantinou J, Morgan-Rowe L. et al. Are there fewer complications with third generation endografts in endovascular aneurysm repair?. J Cardiovasc Surg (Torino) 2013; 54: 133-143
    PubMedSearch in Google Scholar
  • 15 Chuter TA, Gordon RL, Reilly LM. et al. An endovascular system for thoracoabdominal aortic aneurysm repair. J Endovasc Ther 2001; 8: 25-33
    CrossrefPubMedSearch in Google Scholar
  • 16 Sandmann W, Grabitz K, Kniemeyer HW. et al. Surgical treatment of thoraco-abdominal and suprarenal aortic aneurysm. Zentralbl Chir 1988; 113: 1305-1314
    PubMedSearch in Google Scholar
  • 17 Oderich GS, Farber MA, Silveira PG. et al. Technical aspects and 30-day outcomes of the prospective early feasibility study of the GORE EXCLUDER Thoracoabdominal Branched Endoprosthesis (TAMBE) to treat pararenal and extent IV thoracoabdominal aortic aneurysms. J Vasc Surg 2019; 70: 358-368.e6
    CrossrefPubMedSearch in Google Scholar
  • 18 Oderich GS, Ribeiro M, Hofer J. et al. Prospective, nonrandomized study to evaluate endovascular repair of pararenal and thoracoabdominal aortic aneurysms using fenestrated-branched endografts based on supraceliac sealing zones. J Vasc Surg 2017; 65: 1249-1259.e10
    CrossrefPubMedSearch in Google Scholar
  • 19 Antoniou GA, Juszczak MT, Antoniou SA. et al. Editor’s Choice – Fenestrated or Branched Endovascular versus Open Repair for Complex Aortic Aneurysms: Meta-Analysis of Time to Event Propensity Score Matched Data. Eur J Vasc Endovasc Surg 2021; 61: 228-237
    CrossrefPubMedSearch in Google Scholar
  • 20 Rocha RV, Friedrich JO, Elbatarny M. et al. A systematic review and meta-analysis of early outcomes after endovascular versus open repair of thoracoabdominal aortic aneurysms. J Vasc Surg 2018; 68: 1936-1945.e5
    CrossrefPubMedSearch in Google Scholar
  • 21 Rocha RV, Lindsay TF, Friedrich JO. et al. Systematic review of contemporary outcomes of endovascular and open thoracoabdominal aortic aneurysm repair. J Vasc Surg 2020; 71: 1396-1412.e12
    CrossrefPubMedSearch in Google Scholar
  • 22 Boufi M, Patterson BO, Loundou AD. et al. Endovascular Versus Open Repair for Chronic Type B Dissection Treatment: A Meta-Analysis. Ann Thorac Surg 2019; 107: 1559-1570
    CrossrefPubMedSearch in Google Scholar
  • 23 Tanaka A, Leonard SD, Sandhu HK. et al. Open Descending and Thoracoabdominal Aortic Repairs in Patients Younger Than 50 Years Old. Ann Thorac Surg 2019; 108: 693-699
    CrossrefPubMedSearch in Google Scholar
  • 24 Coselli JS, Amarasekara HS, Green SY. et al. Open Repair of Thoracoabdominal Aortic Aneurysm in Patients 50 Years Old and Younger. Ann Thorac Surg 2017; 103: 1849-1857
    CrossrefPubMedSearch in Google Scholar
  • 25 Glebova NO, Cameron DE, Black JH. Treatment of thoracoabdominal aortic disease in patients with connective tissue disorders. J Vasc Surg 2018; 68: 1257-1267
    CrossrefPubMedSearch in Google Scholar
  • 26 Harky A, Hussain SMA, MacCarthy-Ofosu B. et al. The Role of Thoracic Endovascular Aortic Repair (TEVAR) of Thoracic Aortic Diseases in Patients with Connective Tissue Disorders – A Literature Review. Braz J Cardiovasc Surg 2020; 35: 977-985
    CrossrefPubMedSearch in Google Scholar
  • 27 Tschöpe C, Kühl U. Endokarditis-Prophylaxe: Erste Daten nach Lockerung. Dtsch Arztebl Ausg A 2015; 112: A-1574
    PubMedSearch in Google Scholar
  • 28 Wanhainen A, Verzini F, Van Herzeele I. et al. Editor’s Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57: 8-93
    CrossrefPubMedSearch in Google Scholar
  • 29 Munir W, Tarkas TN, Bashir M. et al. Update on graft infections in thoracoabdominal aortic aneurysm surgery. J Cardiovasc Surg (Torino) 2020; 62: 339-346
    CrossrefPubMedSearch in Google Scholar
  • 30 Verma H, Baliga K, George RK. et al. Surgical and endovascular treatment of occlusive aortic syndromes. J Cardiovasc Surg (Torino) 2013; 54 (Suppl. 01) 55-69
    PubMedSearch in Google Scholar
  • 31 Keschenau PR, Ketting S, Mees B. et al. Editor’s Choice – Open Thoracic and Thoraco-abdominal Aortic Repair After Prior Endovascular Therapy. Eur J Vasc Endovasc Surg 2018; 56: 57-67
    CrossrefPubMedSearch in Google Scholar
  • 32 Schuurmann RCL, De Rooy PM, Bastos Goncalves F. et al. A systematic review of standardized methods for assessment of endograft sealing on computed tomography angiography post-endovascular aortic repair, and its influence on endograft-associated complications. Expert Rev Med Devices 2019; 16: 683-695
    CrossrefPubMedSearch in Google Scholar
  • 33 Kansagra K, Kang J, Taon MC. et al. Advanced endografting techniques: snorkels, chimneys, periscopes, fenestrations, and branched endografts. Cardiovasc Diagn Ther 2018; 8: S175-S183
    CrossrefPubMedSearch in Google Scholar
  • 34 Heidemann F, Kolbel T, Debus S. et al. “Surgeon-modified” Stent Grafts in Emergency Cases as Addition to Off-the-shelf Stent Grafts for Complex Abdominal and Thoracoabdominal Aortic Pathologies. Zentralbl Chir 2017; 142: 496-501
    Thieme ConnectPubMedSearch in Google Scholar
  • 35 Heidemann F, Tsilimparis N, Rohlffs F. et al. Staged procedures for prevention of spinal cord ischemia in endovascular aortic surgery. Gefasschirurgie 2018; 23 (Suppl. 02) 39-45
    CrossrefPubMedSearch in Google Scholar
  • 36 Wang J, Wang T, Zhao J. et al. Comparison of Clinical Outcomes Following One versus Two Stage Hybrid Repair of Thoraco-Abdominal Aortic Aneurysms: A Comprehensive Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 61: 396-406
    CrossrefPubMedSearch in Google Scholar
  • 37 Quildrian SD, Nardi WS, David M. Resection of retroperitoneal soft-tissue sarcoma involving the abdominal aorta. BMJ Case Rep 2020; 13: e237107
    CrossrefPubMedSearch in Google Scholar
  • 38 Aucoin VJ, Bolaji B, Novak Z. et al. Trends in the use of cerebrospinal drains and outcomes related to spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair in the Vascular Quality Initiative database. J Vasc Surg 2021;
    CrossrefPubMedSearch in Google Scholar
  • 39 Acher CW, Wynn MM, Mell MW. et al. A quantitative assessment of the impact of intercostal artery reimplantation on paralysis risk in thoracoabdominal aortic aneurysm repair. Ann Surg 2008; 248: 529-540
    CrossrefPubMedSearch in Google Scholar
  • 40 Etz CD, Halstead JC, Spielvogel D. et al. Thoracic and thoracoabdominal aneurysm repair: is reimplantation of spinal cord arteries a waste of time?. Ann Thorac Surg 2006; 82: 1670-1677
    CrossrefPubMedSearch in Google Scholar
  • 41 Estrera AL, Sheinbaum R, Miller CC. et al. Neuromonitor-guided repair of thoracoabdominal aortic aneurysms. J Thorac Cardiovasc Surg 2010; 140 (Suppl. 06) S131-S135
    CrossrefPubMedSearch in Google Scholar
  • 42 Boezeman RP, Moll FL, Unlu C. et al. Systematic review of clinical applications of monitoring muscle tissue oxygenation with near-infrared spectroscopy in vascular disease. Microvasc Res 2016; 104: 11-22
    CrossrefPubMedSearch in Google Scholar
  • 43 Etz DC, Luehr M, Aspern KV. et al. Spinal cord ischemia in open and endovascular thoracoabdominal aortic aneurysm repair: new concepts. J Cardiovasc Surg (Torino) 2014; 55: 159-168
    PubMedSearch in Google Scholar
  • 44 Coselli JS, LeMaire SA, Koksoy C. et al. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair: results of a randomized clinical trial. J Vasc Surg 2002; 35: 631-639
    CrossrefPubMedSearch in Google Scholar
  • 45 Coselli JS, LeMaire SA. Left heart bypass reduces paraplegia rates after thoracoabdominal aortic aneurysm repair. Ann Thorac Surg 1999; 67: 1931-1934
    CrossrefPubMedSearch in Google Scholar
  • 46 Waked K, Schepens M. State-of the-art review on the renal and visceral protection during open thoracoabdominal aortic aneurysm repair. J Vis Surg 2018; 4: 31
    CrossrefPubMedSearch in Google Scholar
  • 47 Henmi S, Ikeno Y, Yokawa K. et al. Comparison of early patency rate and long-term outcomes of various techniques for reconstruction of segmental arteries during thoracoabdominal aortic aneurysm repair. Eur J Cardiothorac Surg 2019;
    CrossrefPubMedSearch in Google Scholar
  • 48 Aucoin VJ, Eagleton MJ, Farber MA. et al. Spinal cord protection practices used during endovascular repair of complex aortic aneurysms by the U.S. Aortic Research Consortium. J Vasc Surg 2021; 73: 323-330
    CrossrefPubMedSearch in Google Scholar