Transkardiale Zugangswege zur endovaskulären Versorgung der Aorta ascendens

Zusammenfassung

Goldstandard der Behandlung von Pathologien der Aorta ascendens ist nach wie vor die offene herzchirurgische Operation mit extrakorporaler Zirkulation in milder bis tiefer Hypothermie, ggf. mit selektiver Kopfperfusion. Allerdings ist dieser Eingriff, insbesondere bei älteren Patienten oder nach bereits stattgehabter Herzoperation, mit einer erheblichen Komplikationsrate vergesellschaftet. Die endovaskuläre Versorgung von Pathologien der thorakalen Aorta (Thoracic endovascular aortic repair/TEVAR) hat sich mittlerweile im Bereich der Aorta descendens zu dem favorisierten Standardverfahren etabliert und zeigt im Vergleich zur offenen operativen Versorgung eine geringere Morbidität und Mortalität. Trotz einer raschen Entwicklung im Bereich der endovaskulären Technik kann der Zugangsweg, insbesondere für die Versorgung der herznahen Aortensegmente, eine Herausforderung darstellen. Der konventionelle, retrograde transfemorale Zugangsweg kann durch starke Knickbildung oder atherosklerotische Plaques der iliakalen und femoralen Zugangsgefäße sowie der Aorta erschwert sein. Ferner ist die große Distanz zum Zielgefäß problematisch für die exakte Graftpositionierung. Um eine praktizierbare Alternative bei der endovaskulären Versorgung herznaher Aortenpathologien zu ermöglichen, sind antegrade transkardiale Zugangswege zur Aorta ascendens und zum Aortenbogen zunehmend bedeutsam.

Abstract

Gold standard for treatment of pathologies of the ascending aorta is still open surgery with extracorporal circulation in moderate to deep hypothermia. These procedures are associated with high morbidity and mortality, especially if performed in older patients or after previous cardiac surgery. Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment option for thoracic aortic pathologies of the descending aorta even in high-risk patients with severe comorbidities resulting in reduced morbidity and mortality compared to open repair. Despite the continuous development of endograft technology an adequate arterial access still poses a relevant limitation of this treatment option accentuated in the proximal segments of the aorta. The transfemoral access may be limited due to severe kinking or arteriosclerotic plaque stenosis of femoral or iliac vessels. Furthermore, the long distance between femoral access vessels and the aortic lesion impairs device torsibility and exact deployment of the stent graft. To provide a practical alternative endovascular access to the ascending aorta, antegrade transcardiac access routes including transapical or transseptal techniques have recently gained increasing interest.

Schlüsselwörter

Aortenstentprothese - Aorta thoracalis - endovaskuläre Therapie - Gefäßintervention - Operationsstrategie - Gefäßchirurgie

Key words

aortic stent prosthesis - thoracic aorta - endovascular treatment - vascular intervention - operative strategy - vascular surgery

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