Endovaskuläre Behandlung akuter Erkrankungen
der thorakalen Aorta

Zusammenfassung

Zielsetzung: Beurteilung der therapeutischen Sicherheit und Effizienz der endovaskulären Behandlung von akuten Erkrankungen der thorakalen Aorta. Material und Methoden: 11 Patienten (Median 55 Jahre; 18 bis 85 Jahre) mit akuten Komplikationen thorakaler Aortenerkrankungen wurden endovaskulär mit einer Stentprothese versorgt (traumatische Aortenruptur (n = 4), Aortenperforation mit aortobronchialer Fistel bzw. Hämatothorax (n = 4), Typ-B-Dissektion mit mesenterialer Ischämie bzw. Ulkuspenetration (n = 2), symptomatisches thorakales Aortenaneurysma (n = 1)). Insgesamt wurden 15 Stentprothesen implantiert (Talent-Prothese n = 11; Vanguard- bzw. Stentor n = 4). 14 Implantationen erfolgten in Allgemeinnarkose, in einem Fall erfolgte der Eingriff in Analgosedierung und Lokalanästhesie. Ergebnisse: 14 Implantationen wurden über eine femorale oder iliacale Arteriotomie durchgeführt. Einmal wurde zunächst ein aortofemoraler Bypass angelegt und die Stentprothese hierüber eingeführt. Das Follow-up beträgt im Median 27 Monate. Bei allen Patienten mit traumatischer Aortenruptur (Verlauf max. 60 Monate) und aortobronchialen Fisteln bzw. penetrierenden Ulzera (Verlauf max. 72 Monate) wurde ein befriedigendes Behandlungsergebnis erzielt. Bei einer akuten Typ-B-Dissektion trat während der Implantation eine retrograde Dissektion im Aortenbogen auf. Neurologische Komplikationen traten nicht auf. Ein Patient mit akuter Typ-B-Dissektion verstarb periinterventionell bei bereits eingetretener Totalnekrose des Darms. Zusammenfassung: Die endovaskuläre Therapie ist bei geeigneter Befundkonstellation zur Versorgung lebensbedrohlicher Komplikationen akuter Aortenerkrankungen geeignet. Regelmäßige Verlaufskontrollen sind notwendig, um potenzielle Spätkomplikationen der Stentprothese frühzeitig erkennen und behandeln zu können.

Abstract

Purpose: To investigate the safety and efficacy of emergency treatment of acute aortic diseases with endovascular stent grafts. Methods: In 11 patients (median age 55 years, range 18 - 85) with acute complications of descending aortic diseases endovascular emergency treatment was performed: traumatic aortic rupture (n = 4), penetrating ulcer with aortobronchial fistula or hematothorax (n = 4), acute type B dissection (n = 2, one with penetration, one with subacute mesenteric ischemia), and symptomatic aneurysm of the thoracic aorta (n = 1) with pain and diameter progression. 15 stent grafts were implanted (Talent n = 11, Vanguard/Stentor n = 4). Stent extension was necessary in 4 cases. In 2 cases graft extension was done during the first procedure (due to distal migration and due to the total length of the aortic aneurysm). In 2 cases graft extension was performed 5 days (due to a new aortic ulcer at the proximal stent struts) and 5 months after the initial procedure (recurrent aortobronchial fistula due to aneurysm progression). 14 of 15 implantations required general anesthesia, one symptomatic thoracic aneurysm was performed in local anesthesia and sedation. Results: 14 of 15 graft procedures were performed using the femoral or iliac approach. One procedure required aortofemoral bypass grafting due to extensive arteriosclerotic stenosis and the stent graft was inserted via the bypass graft. The orifice of the subclavian artery was crossed with bare stent struts in 4 cases without neurological complications. Median follow-up is 27 months (range 6 to 72 months). In traumatic aortic ruptures, immediate sealing of bleeding was achieved and follow-up is inconspicuous at a maximum of 72 months. In cases of aortobronchial fistulas, follow-up is satisfactory (maximum 72 months) despite the necessity for reintervention and graft extension. In one acute type B dissection retrograde dissection of the aortic arch occurred during stent release with stable disease during follow-up without neurological complications. In one type B dissection with mesenteric ischemia the mesenteric blood flow was restored. A second look operation confirmed pulsatile flow in the mesenteric trunk but a total necrosis of the small intestine and the patient consequently died. Conclusion: Endovascular treatment is safe and effective for emergency treatment of life-threatening complications in selected acute aortic syndromes. Mid-term results are encouraging, however, regular follow-up is mandatory to recognize late complications of the stent graft.

Schlüsselwörter

Traumatische Aortenruptur - Penetrierendes Ulkus der Aorta - Aortobronchiale Fistel - Endovaskuläre Therapie - Stentprothese

Key words

Traumatic aortic rupture - Penetrating aortic ulcer - Aortobronchial fistula - Endovascular - Stentgraft

Literatur

• 1 Volodos N L, Karpovich I P, Shekhanin V E, Troian V I, Iakovenko L F. A case of distant transfemoral endoprosthesis of the thoracic aorta using a self-fixing synthetic prosthesis in traumatic aneurysm.  Grudn Khir. 1988;  6 84-86
• 2 Parodi J C, Palmaz J C, Barone H D. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms.  Ann Vasc Surg. 1991;  5 491-499
• 3 Dake M D, Miller D C, Mitchell R S, Semba C P, Moore K A, Sakai T. The „first generation” of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta.  J Thorac Cardiovasc Surg. 1998;  116 689-704
• 4 Umana J P, Mitchell R S. Endovascular treatment of aortic dissections and thoracic aortic aneurysms.  Semin Vasc Surg. 2000;  13 290-298
• 5 Morrissey N J, Yano O J, Soundararajan K, Eisen L, McArthur C, Teodorescu V, Kerstein M, Hollier L, Marin M L. Endovascular repair of paraanastomotic aneurysms of the aorta and the iliac arteries: preferred treatment for a complex problem.  J Vasc Surg. 2001 ;  34 503-512
• 6 Resch T, Koul B, Dias N V, Lindblad B, Ivancev K. Changes in aneurysm morphology and stent-graft configuration after endovascular repair of aneurysms of the descending thoracic aorta.  J Thorac Cardiovasc Surg. 2001;  122 47-52
• 7 Makaroun M S, Deaton D H. Is proximal aortic neck dilatation after endovascular aneurysm exclusion a cause for concern?.  J Vasc Surg. 2001;  33 S39-45
• 8 Nienaber C A, Fattori R, Lund G, Dieckmann C, Wolf W, von Kodolitsch Y, Nicolas V, Pierangeli A. Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.  N Engl J Med. 1999;  340 1539-1545
• 9 Dake M D, Kato N, Mitchell R S, Semba C P, Ravazi M K, Shimono T, Hirano T, Takeda K, Yada I, Miller D C. Endovascular stent-graft placement for treatment of acute aortic dissection.  N Engl J Med. 1999;  340 1546-1552
• 10 Chavan A, Galanski M, Pichlmaier M. Minimal-invasive Therapieansätze bei der Aortendissektion.  Fortschr Geb Röntgenstr Neuen Bildgeb Verfahr. 2000;  172 576-586
• 11 Kato N, Hirano T, Shimono T, Ishida M, Takano K, Nishide Y, Kawaguchi T, Yada I, Takeda K. Treatment of chronic aortic dissection by transluminal endovascular stent-graft placement: preliminary results.  J Vasc Intervent Radiol. 2001;  12 835-840
• 12 Won J Y, Lee D Y, Shim W H, Chang B C, Park S I, Yoon C S, Kwon H M, Park B H, Jung G S. Elective endovascular treatment of descending thoracic aneurysms and chronic dissections with stent-grafts.  J Vasc Inter Radiol. 2001;  12 575-582
• 13 von Segesser L K, Genoni M, Kunzli A, Lachat M, Niederhauser U, Vogt P, Schonbeck M, Turina M. Surgery for ruptured thoracic thoraco-abdominal aortic aneuryms.  Eur J Cardio-thorac Surg. 1996;  10 996-1001
• 14 von Oppell U O, Dunne T T, DeGroot M K, Zilla P. Traumatic aortic rupture: twenty year metaanalysis of mortality and risk of paraplegia.  Ann Thorac Surg. 1994;  58 585-593
• 15 Okhi T, Veith F J, Marin M L, Cynamon J, Sanchez L A. Endovascular approaches for traumatic arterial lesions.  Sem Vasc Surg. 1997;  10 272-285
• 16 Deshpande A, Mossop P, Giurry J, Fryman G, Matalanis G, Malker P, Meckechnie S, Denton M. Treatment of traumatic false aneurysm of the thoracic aorta with endoluminal grafts.  J endovasc Surg. 1998;  5 120-125
• 17 Bruninx G, Wery D, Dubois E, El-Nakadi B, van Dueren E, Verhelst G, Delcour C. Emergency endovascular treatment of an acute traumatic rupture of the thoracic aorta complicated by a distal low-flow syndrome.  Cardiovasc Intervent Radiol. 1999;  22 515-518
• 18 Lobato A C, Quick R C, Phillips B, Vranic M, Rodriguez-Lopez J, Douglas M, Diethrich E B. Immediate endovascular repair for descending thoracic aortic transsection secondary to blunt trauma.  J Endovasc Ther. 2000;  7 16-20
• 19 Bortone A S, Shena S, Mannatrizio G, Paradiso V, Ferlan G, Dialetto G, Cotrufo M, de-Lucca-Tupputi-Schinosa l. Endovascular stent-graft treatment for diseases of the descending throracic aorta.  Eur J Cardiothorac Surg. 2001;  20 514-519
• 20 Taylor P R, Gaines P A, McGuinness C L, Cleveland T J, Beard J D, Cooper G, Reidy J F. Thoracic aortic stent grafts - early experience from two centers using commercially available devices.  Eur J Vasc Endovasc Surg. 2001;  22 70-76
• 21 Dorweiler B, Dueber C, Neufang A, Schmiedt W, Pitton M B, Oelert H. Endovascular treatment of acute bleeding complications in traumatic aortic rupture and aortobronchial fistula.  Eur J Cardiothorac Surg. 2001;  19 739-745
• 22 Miyata T, Ohara N, Shigematsu H, Konishi T, Yamaguchi H, Kazama S, Ohshiro H, Kawaguchi S, Ishimaru S. Endovascular stent graft repair of pulmonary fistula.  J Vasc Surg. 1999;  29 557-560
• 23 Miyata T, Ohara N, Shigematsu H, Konishi T, Yamaguchi H, Kazama S, Ohshiro H, Kawaguchi S, Ishimaru S. Endovascular stent graft repair of pulmonary fistula.  J Vasc Surg. 1999;  29 557-560
• 24 Miyata T, Ohara N, Shigematsu H, Konishi T, Yamaguchi H, Kazama S, Ohshiro H, Kawaguchi S, Ishimaru S. Endovascular stent graft repair of pulmonary fistula.  J Vasc Surg. 1999;  29 557-560
• 25 von Fricken K, Karamanoukian H L, Ricci M, Taheri A, Bergsland J, Salerno T A. Aortobronchial fistula after endovascular stent graft repair of the thoracic aorta.  Ann Thorac Surg. 2000;  70 1407-1409
• 26 Karmy-Jones R, Lee C A, Nicholls S C, Hoffer E. Management of aortobronchial fistula with an aortic stent graft.  Chest. 1999;  116 255-257
• 27 Brittenden J, McBride K, McInnes G, Gillepsie I N, Bradbury A W. The use of endovascular stents in the treatment of penetrating ulcers of the thoracic aorta.  J Vasc Surg. 1999;  30 946-949
• 28 Sailer J, Peloschek P, Rand T, Grabenwoger M, Turnher S, Lammer J. Endovascular treatment of aortic type B dissection and penetrating ulcer using commercially available stent-grafts.  Am J Roentgenol. 2001;  177 1365-1369
• 29 Pitton M B, Düber C, Neufang A, Schlegel J. Endovascular repair of a non-contained aortic rupture caused by a penetrating aortic ulcer. CVIR; in press 2002
• 30 Desgranges P, Mialhe C, Cavillon A, Alric P, Ovarfordt P, Kobeiter H, Mathieu D, Melliere D, Becquemin J P. Endoasvcular repair of posttraumatic throacic pseudoaneurysm with stent graft.  Am J Roentgenol. 1997;  169 1743-1745
• 31 Rousseau H, Soula P, Perreault P, Bui B, d'Othee B J, Massabuau P, Meites G, Concina P, Mazerolles M, Joffre F, Otal P. Delayed treatment of traumatic rupture of the thoracic aorta with endoluminal covered stent.  Circulation. 1999;  99 498-504
• 32 Kato N, Dake M D, Miller D C, Semba C P, Mitchell R S, Razavi M K, Kee S T. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts.  Radiology. 1997;  205 657-662
• 33 Cowley R A, Turney S Z, Hankins J R, Rodriguez A, Attar S, Ahankar B S. Rupture of thoracic aorta caused by blunt chest trauma: a fifteen-year experience.  J Thorac Cardiovasc Surg. 1990;  100 652-661
• 34 Kipfer B, Leupi F, Schuepbach P, Friedli D, Althaus U. Acute traumatic rupture.  Eur J Cardio-thorac Surg. 1994;  8 30-33