Aortendissektion

Zusammenfassung

Das akute Aortensyndrom ist ein moderner Terminus zur Beschreibung von akuten Erkrankungen der Aorta mit ähnlicher klinischer Charakteristik. Es umfasst die klassische Aortendissektion, das intramurale Hämatom (IMH), das penetrierende Aortenulcus (PAU) und die gedeckte Aortenruptur; auch traumatische Intimaläsionen der Aorta werden mit eingeschlossen. Der gemeinsame Nenner des Aortensyndroms ist die Ruptur der Mediaschicht der Aortenwand mit intramuralen Blutungen (IMH) oder mit Entry und Separation der Wandschichten (Dissektion), oder die transmurale Aortenwandruptur wie im Fall eines rupturierten PAU oder nach Dezelerationstrauma. Populationsbasierte Studien haben gezeigt, dass die Inzidenz einer akuten Aortendissektion zwischen 2 und 4 Fällen pro 100000 Personen/Jahr liegt; arterieller Hypertonus und eine Reihe von hereditären Erkrankungen mit pathologischem Bindegewebe stellen die Risikofaktoren mit höchster Prävalenz dar. Patienten mit akutem Aortensyndrom zeigen häufig ein ähnliches klinisches Bild unabhängig von der zugrundeliegenden akuten Pathologie, sei es Dissektion, IMH, PAU oder gedeckte Ruptur. Ein heftiger Schmerz ist das häufigste Symptom des akuten Aortensyndroms mit der Notwendigkeit zur sofortigen Diagnostik inklusive Bildgebung (CT-Angiographie, transösophageale Echokardiographie, MRI). Die Prognose ist eindeutig abhängig von rascher Diagnose und richtiger Behandlung; im Fall der proximalen Aorta ascendens ist eine chirurgische Sanierung erforderlich, bei ausschließlicher Beteiligung der Aorta descendens sollte eine individualisierte therapeutische Entscheidung getroffen werden mit endovaskulärer Therapie bei Malperfusionssyndrom oder drohender Ruptur, und zunächst konservativem Management bei unkomplizierter distaler Dissektion oder IMH. Sogenannte „Aortenteams“ und multidisziplinäre Zusammenarbeit erscheinen äußerst sinnvoll.

Abstract

Acute aortic syndrome (AAS) is a modern term to describe interrelated emergency aortic conditions with similar clinical characteristics and challenges. These conditions include aortic dissection, intramural haematoma (IMH), and penetrating atherosclerotic ulcer (PAU and aortic rupture); trauma to the aorta with intimal laceration may also be considered. The common denominator of AAS is disruption of the media layer of the aorta with bleeding within IMH, along the aortic media resulting in separation of the layers of the aorta (dissection), or transmurally through the wall in the case of ruptured PAU or trauma. Population-based studies suggest that the incidence of acute dissection ranges from 2 to 3.5 cases per 100 000 person/year; hypertension and a variety of genetic disorders with altered connective tissues are the most prevalent risk conditions. Patients with AAS often present in a similar fashion, regardless of the underlying condition of dissection, IMH, PAU, or contained aortic rupture. Pain is the most commonly presenting symptom of acute aortic dissection and should prompt immediate attention including diagnostic imaging modalities (such as multislice computed tomography, transoesophageal ultrasound, or magnetic resonance imaging). Prognosis is clearly related to undelayed diagnosis and appropriate surgical repair in the case of proximal involvement of the aorta; affection of distal segments of the aorta may call for individualized therapeutic approaches favouring endovascular in the presence of malperfusion or imminent rupture, or medical management.

Schlüsselwörter

Aortendissektion - intramurales Hämatom - endovaskuläre Therapie - Malperfusionssyndrom

Keywords

aortic dissection - intramural hematoma - endovascular treatment - malperfusion syndrome

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