Indikationen für Stents in der Arteria femoralis – Sicht des Chirurgen

Zusammenfassung

Die endovaskuläre Therapie der Arteria femoralis superficialis (AFS) erfolgt zunehmend mit der Stent-Technologie: Kurzstreckige Stenosen und langstreckige Verschlüsse werden primär endovaskulär behandelt. In randomisierten Studien wurde gezeigt, dass der Stent in der AFS das Ergebnis nach PTA kurz- bis mittelstreckiger Läsionen nicht verbessert. Seine Indikation hat der Stent als sekundäre Maßnahme zur Bewahrung eines PTA-Ergebisses im Falle einer Komplikation (z. B. bei Gefäßlumenverlegender Dissektion). Neue technische Entwicklungen zielen auf die Behandlung komplexer AFS-Läsionen (TASC Typ C). Stents aus Nitinol, Sirolimus-beschichtete oder PTFE-ummantelte Stents weisen zwar therapeutische Möglichkeiten zur Therapie dieser Läsionen auf, jedoch fehlen randomisierte Studien zu Langzeitergebnissen. Zur Kosten/Nutzenanalyse dieser Verfahren liegen keine Daten vor. Adjunktive Techniken, z. B. Lasertherapie und Brachytherapie, verbesserten die endovaskulären AFS-Therapieergebnisse nicht überzeugend. Komplexe Interventionen bergen das Risiko, einen für den Erhalt der Extremität meist eher harmlosen AFS-Verschluss durch Verletzung des Profundaabgangs oder des Popliteasegments in eine die Extremität bedrohende Läsion zu verwandeln. Hinzu kommt, das die endovaskuläre Therapie mit zunehmender Komplexität der AFSLäsion und bei Diabetes mellitus deutlich schlechtere Ergebnisse als die Bypass-Chirurgie erzielt. Unter Berücksichtigung von evidenzbasierten Kriterien für eine Therapieempfehlung erscheint eine primäre Stent-PTA der AFS meistens nicht gerechtfertigt, weder aus medizinischen noch aus ökonomischen Überlegungen.

Summary

Increasingly, endovascular therapy of the superficial femoral artery (SFA) is performed using stent technology. Not only short stenoses, but also longer lesions are receiving primary endovascular treatment, although several randomized studies have shown that stenting the SFA does not improve the prognosis after PTA of lesions of this size. Rather, the stent is indicated as a secondary measure to preserve the PTA-result should complications such as a dissection occur. New technical developments such as nitinol stents, sirolimus or PTFE coated stents offer the prospect of treating more complex SFA lesions (TASC Typ C). However, randomized studies reporting long term results with such stents have yet to be published and any cost-benefit analysis of stent therapy is questionable due to lack of pertinent data. Adjunctive techniques such as laser or brachytherapy have not shown convincing improvement of endovascular SFA therapy. Compound intervention carries the risk of injury to the branching profunda or the popliteal segment, which can transform an otherwise relatively harmless SFA occlusion into a lesion which may endanger the extremity. Furthermore, increasing complexity of the SFA lesion or lesions in diabetic patients result in markedly worse results when stented, in contrast to treatment employing bypass surgery. Applying evidence based criteria to treatment recommendation shows that primary stent-PTA of the SFA is, in most cases, medically and economically unjustifiable.

Schlüsselwörter

Stents - Arteria femoralis

Keywords

Stents - Arteria femoralis

• Literatur

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