Erkrankungen der thorakalen Aorta – welche Therapie für welchen Abschnitt?

Abstract

The management of thoracic aortic pathology has been evolving to be truly interdisciplinary. The last few years have witnessed the increasing interplay between the open-surgical and endovascular therapy. Based on this, an interdisciplinary approach to diagnosis and therapy is highly recommended. The localization and extent of the pathology is currently the main indicator of the preferred therapy, whether complete surgical, hybrid or complete endovascular. For the aortic root and the ascending aorta, the surgical therapy is the first choice. Pathology of the aortic arch and proximal descending aorta are now preferably treated using a hybrid approach, this means a surgical debranching of the aortic arch with endovascular stenting of the aortic arch and the descending aorta. For the descending aorta, the endovascular stenting is considered the therapy of choice.

The management of the thoracic aorta is undergoing continuous development. Aortic arch pathology has been traditionally treated with complete surgical arch replacement under hypothermic circulatory arrest, which was correlated with high cerebrovascular events. The evolution of aortic arch therapy into arch debranching with selective antegrade cerebral perfusion and endovascular stenting of the aorta improved the neurological results and patient survival substantially. The cardiac surgeons are now working on a transapical endovascular therapy for Stanford Type-A aortic dissection. This therapy form is still in an early phase with a few published case reports but it is considered to be an effective adjuvant to the standard surgical therapy of the aorta in the near future.

Kernaussagen

• Die thorakale Aorta mit ihren Veränderungen und speziellen Erkrankungen ist nicht nur für den Herz- und Gefäßchirurgen eine therapeutische Herausforderung, sondern greift über in weitere Fachgebiete wie die Radiologie und die Angiologie.

• Grundsätzlich stehen 3 therapeutische Optionen im klinischen Alltag zur Verfügung, insbesondere für den Aortenbogen mit seinen supraaortalen Gefäßen: die konventionellen, die hybriden und die rein endovaskulären Verfahren.

• Die konventionelle Chirurgie ist die Methode der Wahl bei Erkrankungen der Aorta ascendens (mit und ohne Aortenklappe) und des Aortenbogens. Im Bereich der Aorta descendens werden vor allem endovaskuläre Stentimplantationen eingesetzt.

• Für jeden Patienten muss ein maßgeschneidertes therapeutisches Konzept erarbeitet werden. Maßgeblich für den Erfolg der eigentlichen operativen/interventionellen Therapieform ist die korrekte Indikationsstellung.

• Die noch sehr neuen Therapiestrategien sollten als ergänzende und nicht als konkurrierende Therapieoptionen bei Erkrankungen der thorakalen Aorta angesehen werden.

• Literatur

• 1 Bentall HH, DeBono A. A technique for complete replacement of the ascending aorta. Thorax 1968; 23: 338-339
• 2 Cabrol C, Pavie A, Gandjbakhch I et al. Complete replacement of the ascending aorta with reimplantation of the coronary arteries. J Thorac Cardiovasc Surg 1981; 79: 309-315
• 3 Wilbring M, Tugtekin S, Alexiou K et al. Composite aortic root replacement for complex prosthetic valve endocarditis: initial clinical results and long tern follow up of high risk patients. Ann Thorac Surg 2012; 94: 1967-1974
• 4 David TE et al. An aortic valve sparing operation for patients with aortic incompetence and aneurysms of the ascending aorta. J Thorac Cardiovasc Surg 1992; 103: 617-622
• 5 Yacoub M et al. Results of valve conserving operations for aortic regurgitation. Circulation 1983; 68: 314-321
• 6 Kappert U, Ghazy T, Ouda A et al. Transapical endovascular stenting of penetrating atherosclerotic ulcer of ascending aorta. Ann Thorac Surg 2013; 96: e101-103
• 7 Acar C, Jebara V, Chachques JC et al. Ascending aortic ectasia. New reinforcement technique. Presse Med 1990; 19: 2031-2033
• 8 Wheat MW, Palmer RF. Dissecting aneurysms of the aorta. Review Article. Current Problems in Surgery 1971; 8: 3-43
• 9 Wilbring M, Ghazy T, Matschke K et al. Complete endovascular treatment of acute proximal ascending aortic dissection and combined aortic valve pathology. J Thorac Cardiovasc Surg 2015; 149: e59-60
• 10 Borst HG, Walterbusch G, Schaps D. Extensive aortic replacement using „elephant trunk“prothesis. J Thorac Cardiovasc Surg 1983; 31: 37-40
• 11 Karck M, Chavan A, Hagl C et al. The frozen elephant trunk technique: A new treatment for thoracic aortic aneurysm. J Thorac Cardiovasc Surg 2003; 125: 1550-1553
• 12 Kappert U, Ouda A, Ghazy T et al. Simultaneous debranching and endovascular repair of thoracic aortic aneurysm in a case with aberrant right subclavian artery. Zeitschrift für vaskuläre und endovaskuläre Medizin, Gefäßchirurgie 2014; 19: 56-59
• 13 Ghazy T, Mashour M, Schmidt T et al. Off pump debranching and thoracic endovascular aortic repair for aortic arch pathology. Innovations (Phila) 2015; 10: 163-169
• 14 Geisbüsch P, Schumacher H, Hyhlik-Dürr A et al. Hybridverfahren zur Therapie aortaler Bogenpathologien. Springer Link 2008; 13: 367-380
• 15 Svensson LG, Kouchoukos NT, Miller DC et al. Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent grafts. Ann Thorac Surg 2008; 85: 1-41
• 16 Ueda K. Incomplete Endograft Apposition to the Aortic Arch: Bird-Beak Configuration Increases Risk of Endoleak Formation after Thoracic Endovascular Aortic Repair. Radiology 2010; 255: 645-652
• 17 Kappert U, Ouda A, Ghazy T et al. Transapical endovascular deployment of a stent graft in the thoracic descending aorta. Ann Thorac Surg 2012; 93: 2063-2065