Therapie des juxtarenalen Aortenaneurysmas

Juxtarenale Aortenaneurysmen machen 15% der Bauchaortenaneurysmen aus. Ihre Behandlung wird durch den kurzen bzw. nicht vorhandenen infrarenalen Hals erschwert. Dieser Beitrag enthält eine Übersicht über die gegenwärtigen offenen und endovaskulären Therapieoptionen, mit einem Fokus auf der elektiven und notfallmäßigen endovaskulären Versorgung der juxtarenalen Bauchaortenaneurysmen.

Abstract

Juxtarenal aortic aneurysms account for 15% of abdominal aortic aneurysms. Compared to infrarenal abdominal aortic aneurysm treatment is more complex due to the missing/short infrarenal neck (0–4mm). To achieve a successful exclusion of the aneurysm the reno-visceral segment has to be involved in treatment. Current standard treatment of elective juxtarenal aortic aneurysms is the custom made fenestrated endovascular aortic repair (cmFEVAR). It has mainly replaced open surgical treatment due to superior perioperative and short term mortality and morbidity. Long-term data did not show superior results of one method so far, but more re-interventions in endovascularly treated patients. In emergency settings surgeon modified fenestrated endovascular aortic repair (smFEVAR) is a valuable therapy option in experienced hands. This technique showed similar technical success and re-intervention rates compared to cmFEVAR. The chimney technique (chEVAR) is another endovascular option, but basically recommended in emergency settings without enough time for smFEVAR, and its use should be limited to two target vessels.

Kernaussagen

• Juxtarenale Aortenaneurysmen machen 15% der Bauchaortenaneurysmen aus.

• Die Behandlung wird durch den kurzen bzw. nicht vorhandenen infrarenalen Hals erschwert.

• Die endovaskuläre Behandlung mit der extra angefertigten fenestrierten Endoprothese (cmFEVAR) hat sich zur Standardbehandlungsmethode entwickelt.

• Die endovaskuläre Behandlung mittels cmFEVAR zeigt eine geringere Morbidität und Mortalität im perioperativen und kurzfristigen postoperativen Verlauf als die offen-chirurgische Behandlung.

• Im Langzeitverlauf zeitigen die offen-chirurgische Versorgung und die endovaskuläre Versorgung ähnliche Ergebnisse in Bezug auf Mortalität und Morbidität. Allerdings ist die Reinterventionsrate nach cmFEVAR höher als die nach offen-chirurgischer Behandlung.

• In der Notfallsituation erzielt die endovaskuläre Versorgung mittels chirurgisch modifizierter Endoprothese (smFEVAR) vergleichbare Ergebnisse bezüglich des technischen Erfolgs und der Reinterventionsraten wie die cmFEVAR.

• Die Chimney-Technik (ChEVAR) ist eine weitere endovaskuläre Behandlungsoption, die vor allem in Notfallsituationen zur Anwendung kommt, wenn keine Zeit zur Anfertigung einer smFEVAR-Prothese bleibt. Diese Methode wird jedoch aufgrund der erhöhten Typ-Ia-Endoleak-Rate nur in Notfallsituationen und für maximal 2 Zielgefäße empfohlen.

Schlüsselwörter

Juxtarenales Aortenaneurysma - extra angefertigte fenestrierte Endoprothese - chirurgisch modifizierte Endoprothese

Keywords

Juxtarenal aortic aneurysm - custom made fenestrated endograft - surgeon modified endograft

Publication History

Article published online:
01 March 2024

• Literatur

• 1 Oderich GS, Factor D. Endovascular aortic repair: current techniques with fenestrated, branched and parallel stent-grafts. Berlin: Springer; 2017
• 2 Jones AD, Waduud MA, Walker P. et al. Meta-analysis of fenestrated endovascular aneurysm repair versus open surgical repair of juxtarenal abdominal aortic aneurysms over the last 10 years. BJS Open 2019; 3: 572-584
• 3 Rao R, Lane TR, Franklin IJ. et al. Open repair versus fenestrated endovascular aneurysm repair of juxtarenal aneurysms. J Vasc Surg 2015; 61: 242-255 DOI: 10.1016/j.jvs.2014.08.068. (PMID: 25240242)
• 4 Deery SE, Lancaster RT, Baril DT. et al. Contemporary outcomes of open complex abdominal aortic aneurysm repair. J Vasc Surg 2016; 63: 1195-1200 DOI: 10.1016/j.jvs.2015.12.038. (PMID: 27109792)
• 5 O’Donnell TF, Boitano LT, Deery SE. et al. Factors associated with postoperative renal dysfunction and the subsequent impact on survival after open juxtarenal abdominal aortic aneurysm repair. J Vasc Surg 2019; 69: 1421-1428
• 6 Takahashi SN, Niimi K, Kodama A. et al. Long-term fate of renal function after open surgery for juxtarenal and pararenal aortic aneurysm. J Vasc Surg 2018; 67: 1042-1050
• 7 British Society for Endovascular Therapy and the Global Collaborators on Advanced Stent-Graft Techniques for Aneurysm Repair (GLOBALSTAR) Registry. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom. Circulation 2012; 125: 2707-2715 DOI: 10.1161/CIRCULATIONAHA.111.070334. (PMID: 22665884)
• 8 AbuRahma AF, DerDerian T, AbuRahma ZT. et al. Comparative study of clinical outcome of endovascular aortic aneurysms repair in large diameter aortic necks (> 31 mm) versus smaller necks. J Vasc Surg 2018; 68: 1345-1353 DOI: 10.1016/j.jvs.2018.02.037. (PMID: 29802043)
• 9 Gallitto E, Faggioli G, Pini R. et al. Proximal aortic coverage and clinical results of the endovascular repair of juxta-/para-renal and type IV thoracoabdominal aneurysm with custom-made fenestrated endografts. Ann Vasc Surg 2021; 73: 397-406
• 10 Crawford ES, Beckett WC, Greer MS. Juxtarenal infrarenal abdominal aortic aneurysm. Special diagnostic and therapeutic considerations. Ann Surg 1986; 203: 661-670 DOI: 10.1097/00000658-198606000-00011. (PMID: 3521511)
• 11 Donas KP, Lee JT, Lachat M. et al. Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: the PERICLES registry. Ann Surg 2015; 262: 546-553 DOI: 10.1097/sla.0000000000001405.
• 12 Li Y, Hu Z, Bai C. et al. Fenestrated and chimney technique for juxtarenal aortic aneurysm: a systematic review and pooled data analysis. Sci Rep 2016; 6: 20497 DOI: 10.1038/srep20497. (PMID: 26869488)
• 13 Touma J, Caradu C, Sylvestre R. et al. Multicentre experience with the chimney technique for abdominal aortic aneurysms in french university hospitals. Eur J Vasc Endovasc Surg 2020; 59: 776-784 DOI: 10.1016/j.ejvs.2020.01.040.
• 14 O’Donnell TFX, Patel VI, Deery SE. et al. The state of complex endovascular abdominal aortic aneurysm repairs in the Vascular Quality Initiative. J Vasc Surg 2019; 70: 369-380 DOI: 10.1016/j.jvs.2018.11.021. (PMID: 30718110)
• 15 Wanhainen A, Verzini F, Van I Herzeele. 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 DOI: 10.1016/j.ejvs.2018.09.020. (PMID: 30528142)
• 16 Wanhainen A, Verzini F, Van I Herzeele. et al. Corrigendum to ’European Society for Vascular Surgery (ESVS) 2019 clinical practice guidelines on the management of abdominal aorto-iliac artery aneurysms‘ [European Journal of Vascular & Endovascular Surgery 57/1 (2019) 8–93]. Eur J Vasc Endovasc Surg 2020; 59: 494 DOI: 10.1016/j.ejvs.2019.11.026. (PMID: 31839474)
• 17 D’Oria M, Wanhainen A, Mani K. et al. Frequency and type of interval adverse events during the waiting period to complex aortic endovascular repair. J Vasc Surg 2022; 75: 1821-1828
• 18 Kimball AS, Mydlowska A, Beck AW. Physician-modified endografts for urgent and emergent aortic pathology. Sem Vasc Surg 2021; 34: 215-224 DOI: 10.1053/j.semvascsurg.2021.07.001. (PMID: 34911627)
• 19 Spanos K, Kölbel T, Heidemann F. et al. Early and mid-term durability of surgeon-modified and custom-made fenestrated devices for the treatment of complex aortic pathology. Ann Vasc Surg 2022; 83: P212-P221 DOI: 10.1016/j.avsg.2021.12.006. (PMID: 34954035)
• 20 Gouveia e Melo R, Fernández Prendes C, Caldeira D. et al. Systematic review and meta-analysis of physician modified endografts for treatment of thoraco-abdominal and complex abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2022; 64: 188e199
• 21 Crawford SA, Sanford RM, Forbes TL. et al. Clinical outcomes and material properties of in situ fenestration of endovascular stent grafts. J Vasc Surg 2016; 64: 244-250 DOI: 10.1016/j.jvs.2016.03.445. (PMID: 27183859)
• 22 Prendes C, Lindström D, Mani K. et al. A systematic review of experimental and clinical studies reporting on in situ laser fenestration of aortic endografts. J Vasc Surg 2022; 75: 740-752 DOI: 10.1016/j.jvs.2021.09.031. (PMID: 34634422)
• 23 Patel SR, Ormesher DC, Griffin R. et al. Editor’s Choice – Comparison of open, standard, and complex endovascular aortic repair treatments for juxtarenal/short neck aneurysms: a systematic review and network meta-analysis. Eur J Vasc Endovasc Surg 2022; 63: 696-706 DOI: 10.1016/j.ejvs.2021.12.042. (PMID: 35221243)