Einflussfaktoren auf das Outcome nach operativer Therapie abdominaler Aortenaneurysmen

Zusammenfassung

Hintergrund: Seit ihrer Einführung hat sich die endovaskuläre Therapie (EVAR) von abdominellen Aortenaneurysmen (AAA) zu einer etablierten Alternative zur offenen Aortenchirurgie (OR) entwickelt. Die Langzeitmortalität nach EVAR und OR ist vergleichbar, während EVAR-Patienten häufiger Komplikationen entwickeln. Einzelne Faktoren mit Einfluss auf das Outcome der AAA-Therapie wurden bereits identifiziert, eine Übersicht fehlt hingegen. Methoden: In einer Literaturrecherche mittels PubMed wurden Publikationen über Einflussfaktoren auf das Ergebnis der operativen Therapie von AAA identifiziert und zusammengetragen. Ergebnisse: Ein Patientenalter > 80 Jahre konnte als signifikanter Prädiktor einer erhöhten postoperativen Mortalität identifiziert werden. Der Einfluss eines Aneurysmadurchmessers > 6,5 cm auf das Therapieergebnis manifestiert sich vor allem bei EVAR-Patienten in Form erhöhter Mortalitäts- und Komplikationsraten. Patienten mit rupturierten AAA versterben signifikant häufiger als Patienten mit intaktem AAA, wobei eine hämodynamische Instabilität mit einer gesteigerten Mortalität assoziiert ist. Kardiovaskulär vorerkrankte Patienten weisen eine verminderte Langzeitüberlebensrate auf. Eine präoperativ begonnene Therapie mit Statinen kann die Kurz- und Langzeitmortalität auf das 0,5-Fache reduzieren. Das Vorliegen chronischer pulmonaler Erkrankungen oder einer Einschränkung der Nierenfunktion geht mit einer erhöhten Mortalität einher. Während das Vorliegen zerebrovaskulärer Erkrankungen mit einem 1,5-fach erhöhten Risiko zu versterben assoziiert ist, zeigten sich für Diabetiker gegensätzliche Ergebnisse, sodass keine eindeutige Aussage bez. der Auswirkungen des Diabetes mellitus möglich ist. Schlussfolgerung: Mehrere Faktoren mit Einfluss auf das Ergebnis der AAA-Therapie stellen Folgen der Erkrankungen dar, die in die Pathogenese von AAA involviert sind. Der Einfluss natürlicher Faktoren wie Alter und Aortendurchmesser kann durch Ultraschallscreening reduziert werden. Die Optimierung der Behandlung krankheitsbezogener Risikofaktoren verbessert das Therapie-Outcome. Das entsprechend optimale Operationsverfahren bei Patienten mit Risikofaktoren sollte in weiteren Studien untersucht werden.

Abstract

Background: Since its introduction, endovascular aortic aneurysm repair (EVAR) has proved as a favourable alternative to open surgery (OR) in the treatment of abdominal aortic aneurysms (AAA). Long-term outcomes of EVAR and OR are similar while complications are more likely to develop after EVAR. Risk factors for mortality and complications after AAA surgery have been identified, however, a general overview is lacking. Methods: In a systematic literature search via PubMed, we identified publications on the topic of factors influencing the postoperative outcome of AAA surgery. Results: Patient age > 80 years was found to be a significant predictor of increased mortality, whereas the influence of aneurysm diameter on OR remains moderate, the outcome of EVAR performed in AAA > 6.5 cm is associated with higher mortality and increased complication rates. In patients with ruptured AAA the postoperative mortality is higher than in those with intact aneurysms. Preoperative haemodynamic instability has a crucial influence on patient outcome and is strongly associated with intra- and postoperative death. The prevalence of cardiovascular co-morbidity leads to increased long-term mortality. Preoperative statin medication was found to reduce short- and long-term mortality by the factor of 0.5. Patients suffering from chronic lung disease such as COPD and patients with a deficiency in renal function are more likely to experience adverse events including death. While the prevalence of cerebrovascular disease is associated with an increase in mortality by the factor of 1.5 or higher, findings on patients with diabetes mellitus are conflicting with no definite point to be made. Conclusion: Several factors influencing the outcome of surgery for AAA present a condition developed from factors involved in the pathogenesis of AAA. The impact of non-disease factors like patient age and aneurysm diameter can be reduced by the means of population-wide screening for AAA, and optimised treatment of disease-related risk factors can reduce mortality. Studies comparing the outcome of EVAR and OR in patients with risk factors should be performed to support decision-making about the ideal individual treatment.

Schlüsselwörter

abdominales Aortenaneurysma - EVAR - offene Aneurysmaresektion - Outcome - Einflussfaktor

Key words

abdominal aortic aneurysm - EVAR - open aneurysm resection - outcome - impacting factors

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