Endovaskuläre Therapie von abdominellen Aortenaneurysmen: Klinisch-radiologische Ergebnisse im mittelfristigen Verlauf

Zusammenfassung

Zielsetzung: Prospektive Studie zur Erfassung der klinisch-radiologischen Ergebnisse und Komplikationen im mittelfristigen Verlauf nach endovaskulärer Aneurysmatherapie. Material und Methoden: 122 Patienten (9 Frauen, 113 Männer, Alter 70,9 ± 7,9 Jahre) mit abdominellen Aortenaneurysmen wurden mittels Stentprothesen endovaskulär behandelt (Vanguard/Stentor n = 53, Talent n = 69). Patienten mit verschlossenen aortalen Seitenästen im Aneurysmabereich (spontan oder nach Embolisationsbehandlung) wurden in Gruppe I (n = 40) zusammengefasst, Patienten mit mindestens einem perfundierten Seitenast in Gruppe II (n = 82). Die Implantationen erfolgten zunächst in Allgemeinnarkose (n = 21), später in Periduralanästhesie (n = 15) und schließlich in Lokalanästhesie (n = 86). Die Ergebniskontrollen erfolgten mittels Spiral-CT, MRT und Stent-Radiographie postinterventionell, nach 3, 6 und 12 Monaten, dann jährlich. Ergebnisse: Die Implantationen wurden in allen Fällen erfolgreich durchgeführt, ohne primäre Konversionsoperationen, Laparotomien oder sonstige schwerwiegende Komplikationen. Die Nachbeobachtung betrug 29 ± 21 Monate, maximal 84 Monate. Die 30-Tage-Mortalität betrug 0,8 % (Myokardinfarkt 3 Tage nach Entlassung aus stationärer Behandlung). Bei 29 Patienten (23,8 %) waren 47 Reinterventionen erforderlich (35 Eingriffe bei 18 Vanguard-Prothesen, 12 Eingriffe bei 11 Talent-Prothesen): 23 perkutane Eingriffe (distale Stentextensionen [n = 11], Wallstents zur Beseitigung von Schenkelstenosen/-knickungen [n=3], sekundäre Embolisationen von aortalen Seitenästen wegen Endoleaks [n = 9]) und 24 operative Re-Eingriffe (proximale Stentextension [n = 6], neue Stentprothesen [n = 3], operatives Clipping von Seitenästen [n = 1], femorofemorale Querbypasses [n = 4], sekundäre Konversionsoperationen [n = 10]). Im Vergleich zu Gruppe II waren die Inzidenz und Größe von Endoleaks in Gruppe I deutlich geringer (Inzidenz 19,2 % versus 29,9 %, p < 0,05). Aneurysmen mit primärem Verschluss aller aortalen Seitenäste zeigten eine bessere Größenreduktion im Verlauf (Durchmesseränderung [sagittal] nach 36 Monaten - 11,1 ± 8,4 versus - 4,9 ± 6,2 mm, p < 0,05). Schlussfolgerungen: Bei geeigneten anatomischen Voraussetzungen ist die endovaskuläre Methode eine Alternative zum chirurgischen Aortenersatz. Sie kann mit geringer Mortalität und Morbidität in Lokalanästhesie durchgeführt werden. Im mittelfristigen Verlauf waren in ca. einem Viertel der Fälle perkutane oder operative Reinterventionen erforderlich, vorwiegend bei Vanguard bzw. Stentor-Prothesen. Die primäre Embolisation der aortalen Seitenäste verbessert das klinische Behandlungsergebnis. Die proximale Fixierung der Stentprothesen ist bisher nicht befriedigend gelöst.

Abstract

Purpose: Prospective study to evaluate clinical results and complications of endovascular abdominal aortic aneurysm treatment in a mid-term follow-up. Materials and Methods: A total of 122 patients (9 females, 113 males, average age 70.9 ± 7.9 years) with abdominal aortic aneurysms were treated with stent grafts (53 Vanguard or Stentor endografts, 69 Talent endografts). Group I consisted of 40 patients who had all aortic tributaries of the aneurysm sac occluded prior to endovascular grafting, either spontaneously by parietal thrombosis or by selective coil embolization of the respective ostia preserving collateral circulation distal to the vessel occlusion. Group II consisted of 82 patients and included all cases without or with incomplete coil embolization with at least one patent vessel. Stent grafting was performed in general anesthesia in the first 21 patients, followed by peridural anesthesia in 15 cases, and local anesthesia with conscious sedation in 86 cases. The results were evaluated with Spiral-CT, MRI and radiographs of the endovascular graft, with follow-up examinations obtained at 3, 6, 12 months, and every year. Results: Implantation was successfully completed in all cases without primary conversion surgery, laparotomy, or any significant complication. Mean follow-up was 29 ± 21 months (maximum 84 months). The 30-day mortality was 0.8 % due to a myocardial infarction 3 days after discharge from the hospital. A total of 47 re-interventions were performed in 29 patients (23.8 %), with 35 re-interventions in 18 cases with Vanguard or Stentor endografts and 12 re-interventions in 11 patients with Talent endografts. 23 percutaneous re-interventions included distal graft extension (n = 11), Wallstents for kinking and limb stenosis (n = 3), and secondary coil embolization of collateral vessels (n = 9). 24 surgical re-interventions included proximal graft extension (n = 6), new endovascular grafts (n = 3), surgical clipping of lumbar and mesenteric artery branches for type-II endoleaks following ineffective secondary coil embolization (n = 1), and femorofemoral crossover bypasses (n = 4). A total of 10 secondary conversion operations were performed because of damage to the membrane (n = 4; 3 Vanguard endografts, 1 Talent endograft), significant caudal migrations (n = 5; 4 Vanguard endografts, 1 Talent endograft) associated with type-I endoleaks (n = 2), limb occlusion (n = 1), disconnection of graft components (n = 1), and significant endoluminal thrombus deposits (n = 1). One patient, who was followed for 82 months, suffered from a significant endoleak for 10 months with increasing aneurysm diameter but he refused surgery. He was admitted with aneurysm perforation and was successfully operated with aortic graft replacement. Compared to group II, the incidence and size of endoleaks was reduced in group I (incidence 19.2 % versus 29.9 %, p < 0.05). Group I demonstrated significantly better aneurysm shrinkage at 36 months follow-up (Δ sagittal diameter - 11.1 ± 8.4 mm versus - 4.9 ± 6.2 mm, p < 0.05). Conclusion: In selected patients, endovascular aneurysm treatment is an effective alternative to open surgery. It is safely performed in local anesthesia with low mortality rate and a low number of acute complications. Intermediate follow-up revealed re-interventions in around one quater of all patients, especially when Vanguard or Stentor endografts were implanted. Primary coil embolization of all aortic branches prior to endovascular grafting improves clinical outcome. Insufficient proximal fixation and its consecutive complications remains a major problem of this method.

Key words

Abdominal aortic aneurysm - endovascular treatment - stent grafts, endoleaks

Literatur

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1 Die vorliegende Arbeit enthält wesentliche Anteile der Dissertation von Frau Henriette Schweitzer