Zusammenfassung
Hintergrund
Die offene Operation stellt aktuell den „Goldstandard“ für die Versorgung der Aorta ascendens und des Aortenbogens dar. Die konventionellen Operationstechniken erfordern allerdings einen hypothermen Kreislaufstillstand, der mit relevanten Komplikationen assoziiert ist. Die minimalinvasive Therapie von pathologischen Veränderungen des Aortenbogens bedeutet aufgrund der komplexen Probleme dieser vaskulären Region eine technische Herausforderung. Die aus dem Aortenbogen abgehenden Abzweigungen versorgen u. a. das Gehirn, das eine minimale Ischämietoleranz hat. Weiterhin ist der Aortenbogen weit, gebogen, stärker pulsatil und weiter von den Femoralarterien entfernt.
Ergebnisse
Die endovaskulären Therapieoptionen zur Behandlung von pathologischen Veränderungen der Aorta ascendens und des Aortenbogens sind Hybridtechniken im Aortenbogen, Chimney-Prozeduren für die supraaortalen Äste, In-situ-Fenestration von thorakalen Stent-Prothesen sowie individuell angefertigte fenestrierte und gebranchte Stent-Prothesen. Individuell angefertigte fenestrierte und gebranchte Stent-Prothesen sind eine sehr gute Option für Patienten, die für offene Operation nicht geeignet sind, und könnten in der Zukunft die endovaskuäre Therapie der Wahl werden.
Schlussfolgerung
Eine gute präoperative Planung, die exakte Kenntnis der individuellen anatomischen Verhältnisse sowie das Verständnis der Besonderheiten der Aorta ascendens und des Aortenbogens sind für die erfolgreiche endovaskuläre Versorgung entscheidend.
Abstract
Background
Open surgery for pathologies of the ascending aorta and the aortic arch represents the gold standard of treatment. Conventional open repair techniques, however, require hypothermic circulatory arrest which is associated with relevant complications. Minimally invasive therapy of the aortic arch represents an alternative for patients not suitable for open therapy; however, it is a challenge due to the complexity of this vascular region. The supra-aortic branches perfuse the brain which has a minimal tolerance to ischemia time. Furthermore, the aortic arch may be wide, angulated, more pulsatile and at a greater distance from the femoral access vessels than the rest of the aorta.
Results
Endovascular options for treatment of pathologies of the ascending aorta and the aortic arch include hybrid debranching procedures, chimney grafts for the supra-aortic vessels, in situ fenestration of thoracic endografts and customized fenestrated branched stent grafts. Customized fenestrated branched endografts appear to be a very good option for patients unfit for open surgery and could potentially become the endovascular treatment of choice.
Conclusion
Irrespective of the endovascular treatment selected, detailed preoperative planning and understanding of the specific characteristics of the ascending aorta and the aortic arch are of paramount importance to achieve a good outcome.
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Einhaltung ethischer Richtlinien
Interessenkonflikt. N. Tsilimparis: Kongressreiseunterstützung von Cook Medical, E.S. Debus: keine, S.W. Carpenter: keine, S. Wipper: keine, H. Diener: keine, A. Larena-Avellaneda: keine, T. Kölbel: Patentrechte für Fa. Cook Medical. Der Beitrag enthält keine Studien an Menschen oder Tieren.
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Tsilimparis, N., Debus, E., Wipper, S. et al. Endovaskuläre Versorgung von Pathologien der Aorta ascendens und des Aortenbogens. Gefässchirurgie 19, 436–442 (2014). https://doi.org/10.1007/s00772-014-1338-6
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DOI: https://doi.org/10.1007/s00772-014-1338-6