Differenzielles gefäßmedizinisches Management des Viszeralarterienaneurysmas anhand einer unizentrischen konsekutiven Patientenkohorte im Rahmen einer laufenden krankheitsspezifischen, klinisch-systematischen, prospektiven Observationsstudie

Zusammenfassung

Ziel, Patienten und Methode: Im Rahmen einer systematisch-klinischen, unizentrischen, prospektiven Observationsstudie an einem universitären chirurgischen (tertiären) Zentrum wurden Spektrum (Symptomatik, Häufigkeit) und Diagnostik der unterschiedlichen Aneurysmalokalisationen sowie der postinterventionelle Verlauf der jeweils befundgerecht angewandten diversen Therapieoptionen analysiert, um die Vorgehensweisen (konservativ, interventionell-radiologisch, offen-gefäßchirurgisch) hinsichtlich der Entscheidungskriterien und ihres frühen postinterventionellen Outcomes (anhand von Komplikationsrate, periinterventioneller Morbidität und Hospitalletalität) Literaturangaben gegenüberzustellen. Ergebnisse: Über einen 14-Jahres-Zeitraum wurden 22 Patienten eingeschlossen (12 Männer/10 Frauen; Durchschnittsalter: 54,3 [Spannbreite: 22–76] Jahre). Am häufigsten waren Viszeralarterienaneurysmata mit 50 % an der A. lienalis lokalisiert, in jeweils 13,6 % (n = 3/22) die A. gastroduodenalis, die A. hepatica propria, die A. renalis dextra und in 9,1 % (n = 2/22) die A. mesenterica superior betroffen. Die Mehrzahl der Patienten (54,5 %) wurde interventionell-radiologisch behandelt, 31,8 % offen-chirurgisch therapiert und 13,6 % konservativ mittels Verlaufsbeobachtung betreut. Die Majorkomplikationsrate betrug 21,1 % (n = 4/19) und die Gesamthospitalletalität 9,1 % (n = 2/22). Schlussfolgerung: Die Wahl des spezifischen therapeutischen Vorgehens und eine Entscheidung dafür sollte 1. nach adäquater bildgebender Diagnostik (transabdominaler Ultraschall, MR-Angiografie, Duplex-Sonografie, ggf. CT-A/DSA), 2. angebunden an ein gefäßchirurgisches Zentrum, 3. befundadaptiert (insbesondere nach Größe/spezifischer Rupturwahrscheinlichkeit [CAVE: Gravidität]) und 4. angepasst an das individuelle Risikoprofil des Patienten sowie 5. unter angemessener Nutzung der vorhandenen Therapieoptionen (konservativ vs. interventionell; interventionell-radiologische [endovaskuläres Repair mittels Embolisation, Stent oder Prothesenstent] vs. offene Versorgung [nach Stufenschema]; offene Gefäßligatur vs. -rekonstruktion nach Aneurysmaausschaltung) bei suffizienter Qualitätssicherung der Behandlungsresultate wie auch duplexsonografischer (ggf. MR-angiografischer) Nachsorge in angemessenen Untersuchungsintervallen mit empfehlenswerter gefäßchirurgischer Sprechstundenanbindung vorgenommen werden.

Abstract

Aim, Patients and Methods: By means of a systematic single-centre prospective observational study, spectrum (symptomatology, frequency) and diagnostics of the different visceral artery aneurysm sites as well as the postinterventional course of the various therapeutic options used according to local finding and patientʼs clinical status as well as risk factors were analysed to contrast the different procedures (conservative, image-guided radiological intervention, open vascular surgery) in consideration of their decision-making criteria and their early postinterventional outcome (on the basis of complication rate, peri-interventional morbidity and hospital lethality) including relevant references from the literature. Results: During a time period of 14 years, 22 patients (sex ratio: 12 males/10 females; mean age: 54.3 [range: 22–76] years) were registered. Most frequently, visceral artery aneurysms occurred in the splenic artery (50 %). The gastroduodenal artery, the hepatic artery and the right renal artery were affected in each with 13.6 % (n = 3/22), the superior mesenteric artery in 9.1 % (n = 2/22). The majority of patients (54.5 %) were treated with image-guided radiological intervention, whereas in 31.8 %, the patient underwent open vascular surgery and 13.6 % of cases were managed with “watchful waiting”. While morbidity was 21.1 % (n = 4/19), overall lethality was 9.1 % (n = 2/22). Conclusion: Decision-making for a specific therapeutic approach should be made (i) after adequate diagnostic measures (transabdominal ultrasound, MR angiography, duplex ultrasonography, CT-A/DSA if required), (ii) on an individual case-adapted base, (iii) in a vascular surgical centre, (iv) case-associated to the specific local finding (in particular, according to size/specific probability of rupture [cave: gravidity]) and (v) according to the individual risk profile using the whole spectrum of therapeutic options (conservative vs. interventional; image-guided radiological intervention [endovascular repair such as embolisation, stent or stent graft] vs. open vascular surgery [according to a step-up approach]; open vascular ligation vs. reconstruction after exclusion of the aneurysm) including sufficient quality assurance of the treatment results as well as control investigations (duplex ultrasonography; MR-A if required) in a specialised vascular surgical out-patient centre within appropriate time intervals.

Schlüsselwörter

Viszeralarterienaneurysma - MRA - DSA - interventionell-radiologisches Vorgehen - gefäßchirurgische Operation

Key words

visceral artery aneurysm - MRA - DSA - image-guided radiological intervention - vascular surgical intervention

^* Beide Autoren sind gleichberechtigte Erstautoren.

• Literaturverzeichnis

• 1 Koganemaru M, Abe T, Nonoshita M et al. Follow-up of true visceral artery aneurysm after coil embolization by three-dimensional contrast-enhanced MR angiography. Diagn Interv Radiol 2014; 20: 129-135
• 2 Meyer A, Uder M, Lang WCR. [Visceral artery aneurysms]. Zentralbl Chir 2010; 135: 416-420
• 3 Edogawa S, Shibuya T, Kurose K et al. Inferior mesenteric artery aneurysm: case report and literature review. Ann Vasc Dis 2013; 6: 98-101
• 4 Carr SC, Pearce WH, Vogelzang RL et al. Current management of visceral artery aneurysms. Surgery 1996; 120: 627-633
• 5 Cordova A, Sumpio B. Visceral artery aneurysms and pseudoaneurysms – should they all be managed by endovascular techniques?. Ann Vasc Dis 2013; 6: 687-693
• 6 Hossain A, Reis ED, Dave SP et al. Visceral artery aneurysms: experience in a tertiary-care center. Am Surg 2001; 67: 432-437
• 7 Brocker J, Maher J, Smith R. True pancreaticoduodenal aneurysms with celiac stenosis or occlusion. Am J Surg 2012; 204: 762-768
• 8 Hildebrand P, Esnaashari H, Franke C et al. Surgical management of pancreaticoduodenal artery aneurysms in association with celiac trunk occlusion or stenosis. Ann Vasc Surg 2007; 21: 10-15
• 9 Kalko Y, Ugurlucan M, Basaran M et al. Visceral artery aneurysms. Heart Surg Forum 2007; 10: E24-29
• 10 Melissano G, Chiesa R. Successful surgical treatment of visceral artery aneurysms: after failure of percutaneous treatment. Texas Heart Inst J 1998; 25: 75-78
• 11 Teng W, Sarfati MR, Mueller MT et al. A ruptured pancreaticoduodenal artery aneurysm repaired by combined endovascular and open techniques. Ann Vasc Surg 2006; 20: 792-795
• 12 Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am 1997; 77: 425-442
• 13 Hiramoto JS, Messina LM. Visceral artery aneurysms. Curr Treat Options Cardiovasc Med 2005; 7: 109-117
• 14 Kebede T, Tequabo Y. Ruptured splenic artery aneurysm as a rare cause of acute abdomen; a case report done at Tikur Anbessa Specialized Hospital, Addis Ababa. Ethiop Med J 2012; 50: 95-98
• 15 Piffaretti G, Lomazzi C, Carrafiello G et al. Visceral artery: management of 48 cases. J Cardiovasc Surg (Torino) 2011; 52: 557-565
• 16 Balderi A, Antonietti A, Ferro L et al. Endovascular treatment of visceral artery aneurysms and pseudoaneurysms: our experience. Radiol Med 2012; 117: 815-830
• 17 Grotemeyer D, Duran M, Park E et al. Visceral artery aneurysms- follow-up of 23 patients with 31 aneurysms after surgical of interventional therapy. Langenbecks Arch Surg 2009; 394: 1093-1110
• 18 Mazzaccaro D, Carmo M, Nano G et al. Treatment options for visceral artery aneurysms: ten year experience. J Cardiovasc Surg (Torino) 2013; Jul 18 [Epub ahead of print]
• 19 Muscari F, Barret A, Chaufour X et al. Management of visceral artery aneurysms. Retrospective study of 23 cases. Ann Chir 2002; 127: 281-288
• 20 Popov P, Boskovic S, Sagic D et al. Treatment of visceral artery aneurysms: retrospective study of 35 cases. Vasa 2007; 36: 191-198
• 21 Sessa C, Tinelli G, Porcu P et al. Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg 2004; 18: 695-703
• 22 Stone WM, Abbas MA, Cherry KJ et al. Superior mesenteric artery aneurysms: is presence an indication for intervention?. J Vasc Surg 2002; 36: 234-237
• 23 Saltzberg SS, Maldonado TS, Lamparello PJ et al. Is endovascular therapy the preferred treatment for all visceral artery aneurysms?. Ann Vasc Surg 2005; 19: 507-515
• 24 Halloul Z, Meyer F, Tautenhahn J et al. Das Management von Aneurysmata peripankreatischer Arterien: 2 Kasuistiken. Zentralbl Chir 2002; 127: 141-143
• 25 Yankovic W, Febrer G, Couture T et al. Hybrid repair of a hepatic artery aneurysm. Ann Vasc Surg 2012; 26: e1-3
• 26 Carmeci C, McClenathan J. Visceral artery aneurysms as seen in a community hospital. Am J Surg 2000; 179: 486-489
• 27 Chiesa R, Astore D, Guzzo G et al. Visceral artery aneurysms. Ann Vasc Surg 2005; 19: 42-48
• 28 Lauschke H, Rudolph J, Textor J et al. [Visceral artery aneurysms]. Zentralbl Chir 2002; 127: 538-542
• 29 Reardon PR, Otah E, Craig ES et al. Laparoscopic resection of splenic artery aneurysms. Surg Endosc 2005; 19: 488-493
• 30 Ruiz-Tovar J, Martinez-Molina E, Morales V et al. Evolution of the therapeutic approach of visceral artery aneurysms. Scand J Surg 2007; 96: 308-313
• 31 Marone E, Mascia D, Kahlberg A et al. Is open repair still the gold standard in visceral artery aneurysm management?. Ann Vasc Surg 2011; 25: 936-946
• 32 Stone WM, Abbas MA, Gloviczki P et al. Celiac arterial aneurysms: a critical reappraisal of a rare entity. Arch Surg 2002; 137: 670-674
• 33 Tarbaeva NV, Kokov LS. Diagnosis and management of visceral arteries aneurysms. Angiol Sosud Khir 2006; 12: 135-137
• 34 Wierzbicki T, Szmeja J, Borejsza-Wysocki M et al. Massive bleeding from upper gastrointestinal tract as a symptom of rupture of splenic artery aneurysm to stomach. Med Sci Monit 2012; 18: CS8-11
• 35 Halloul Z, Meyer F, Grote R et al. Selective embolization of splenic artery aneurysm – case report. Eur Surg 2005; 37: 59-62
• 36 Ha JF, Sieunarine K. Laparoscopic splenic artery aneurysm resection: review of current trends in management. Surg Laparosc Endosc Percutan Tech 2009; 19: e67-70
• 37 Pulli R, Dorigo W, Troisi N et al. Surgical treatment of visceral artery aneurysms: a 25-year experience. J Vasc Surg 2008; 48: 334-342