Rekonstruktion der vaskulär kompromittierten unteren Extremität – Bericht des Consensus-Workshops im Rahmen der 35. Jahrestagung der DAM 2013 in Deidesheim

Zusammenfassung

Einleitung: Nachdem die mikrochirurgische Rekonstruktion bei Patienten mit kritischen Perfusionsstörungen und arterieller Verschlusskrankheit in mehreren Zentren zunehmend durchgeführt wird, besteht die Notwendigkeit einer Standardisierung des interdisziplinären Diagnostik- und Therapieregimes bei diesen kritisch kranken Patienten. Im Rahmen eines Consensus-Workshops zur Rekonstruktion der vaskulär kompromittierten unteren Extremität anlässlich der 35. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße 2013 in Deidesheim wurden durch Mitglieder der DAM zusammen mit Gefäßchirurgen und interventionellen Radiologen die Diagnose- und Therapiemöglichkeiten bei diesen Fragestellungen eruiert, interdisziplinär diskutiert und wesentliche Empfehlungen festgehalten.

Methode: Anhand einer Literaturrecherche und der Ergebnisse der Expertendiskussion werden die Therapiemöglichkeiten und -grenzen aufgezeigt und Hinweise zur erfolgreichen Rekonstruktion durch Kooperation gegeben.

Ergebnisse: Durch die interdisziplinäre Zusammenarbeit können Extremitäten erhalten werden und dadurch nicht nur die Lebensqualität verbessert, sondern – wie sich anhand von Literaturdaten zeigt – auch die Lebensdauer von schwer gefäßerkrankten Patienten verlängert werden. Es wurden unterschiedliche Konzepte für diese Patientengruppe entwickelt, bei denen ein- oder mehrzeitige rekonstruktive Eingriffe mit gefäßerweiternden Verfahren, alleine oder in Kombination mit unterschiedlichen Konfigura­tionen von autologen Bypasses zur differenzierten Anwendung kommen. Freie Lappenplastiken erhalten durch die Revaskularisierung im Sinne eines „nutrient flap“ Anschlussmöglichkeiten und können zu einer verbesserten Perfusion der unteren Extremität beitragen. Die erhöhten perioperativen Risiken erscheinen bei sorgfältiger präoperativer Evaluation und adäquater Indikationsstellung für die Patienten vertretbar.

Diskussion: Der schlechte Allgemeinzustand der Patienten ­erfordert eine entsprechende interdisziplinäre präoperative Planung, die auf den Einzelfall abgestimmt werden muss. Der ­Anschluss von freien Lappen auf einen Bypass oder an eine rekanalisierte Gefäßachse ermöglicht nicht nur die Deckung von großen Defekten, er stellt auch durch die Erhöhung des Blutflusses im Bypass einen hämodynamischen Vorteil dar. Dies ist auf das zusätzliche Gefäßbett zurückzuführen, das mit dem freien Lappen transplantiert wird. Der Erhalt der Mobilität bietet für dieses Patientengut wesentliche Vorteile, wobei stets der initial weniger belastende Eingriff der Amputation auch in Betracht gezogen werden muss.

Abstract

Introduction: As microsurgical reconstruction is now being increasingly performed on patients with critical peripheral perfusion and/or arterial occlusive disease in numerous centres, there is a need for standardisation of interdisciplinary diagnostic approach and treatment regimens in such critically ill patients. In a consensus workshop on reconstruction of the vascular compromised lower extremity during the 35th Annual Meeting of the German working group microsurgery of the peripheral nerves and vessels (DAM) in 2013 in Deidesheim, DAM members together with vascular surgeons and interventional radiologists attempted to establish interdisciplinarily routine pathways for diagnosis and therapy and to consolidate key recommendations for treatment.

Methods: By reviewing the literature and considering the results of the expert meetings, options and limits of therapy were illustrated and recommendations for successful cooperative treatment formulated.

Results: By means of interdisciplinary cooperation, limbs can be salvaged and the quality of live as well as survival of patients with severe peripheral vascular disease improved. Different techniques including angioplasty, bypass surgery and microsurgical free flaps can be applied and individualised concepts allow extremity salvage even in patients with severely compromised limbs. Revascularisation provides the possibility of free flap transfer while the risk for the patients is moderate.

Discussion: The poor general condition of the patient requires a sufficient interdisciplinary preoperative planning. By means of interdisciplinary cooperation, the limbs can be salvaged. This not only improves the quality of life but also increases the survival time of patients with occlusive vascular disease. Different concepts for this group of patients have been developed. Surgical treatment with a distal bypass or recanalisation and free flap not only allow for the coverage of large defects, but also represent a haemodynamic advantage by increased blood flow in the bypass. This is attributed to the additional vascular bed that is transplanted with the free flap. Limb salvage means relevant improvement, however, the initially less demanding procedure of amputation must always be considered.

Schlüsselwörter

Unterschenkelrekonstruk­tion - untere Extremität - freie Lappenplastiken - Mikrochirurgie - Weiterbildung

Key words

lower leg reconstruction - lower limb - free flap plasty - continuing medical training

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