Therapie der Extremitätenarterienaneurysmen – Dual Supera bei Popliteaaneurysma: Sofort- und Langzeitergebnisse

Zusammenfassung

Popliteaaneurysmen zeigen die höchste Inzidenz peripherer Aneurysmen. Hierbei steht klinisch nicht die Ruptur, sondern die chronische Embolisation mit Ausbildung einer irreversiblen Ischämie und der damit assoziierten Amputation und Mortalität im Vordergrund. Mittlerweile ist die endovaskuläre Therapie als Alternative zum offen chirurgischen Vorgehen basierend auf verlässlichen Daten etabliert. Das im zerebralen Segment seit Langem angewandte, aber für die Gefäßperipherie wenig beachtete Prinzip der flussmodulierenden Stentsysteme zeigt auch im femoropoplitealen Gefäßsegment vielversprechende Ergebnisse und stellt den Grundsatz der kompletten endovaskulären Ausschaltung durch gecoverte Stents oder die Bypassumgehung des Aneurysmas infrage. Seit 2011 wurden 34 von 142 elektiven und 8 thrombosierte Popliteaaneurysmen mit einem für den Einsatz im arteriellen System zugelassenen gewobenen Nitinol-Stent versorgt und nachbeobachtet. In der hier beschriebenen monozentrischen Serie mit mittel- bis langfristiger Nachbeobachtung zeigte sich das Verfahren hinsichtlich der Aneurysmaausschaltung, der Offenheitsrate, der Materialermüdung und des Erhalts der Ausstrombahn mit der Option der Konversion mit den gängigen Methoden vergleichbar. Die Limitierung der Methode ist durch die maximalen Stentdurchmesser von 7,5 mm bedingt.

Abstract

Popliteal aneurysms have the highest incidence of all peripheral aneurysms. The clinical symptoms are dominated by chronic embolism, resulting in irreversible ischemia with the associated risk of amputation and mortality, but rupture is less important. Acute aneurysm thrombosis bears a high risk of amputation and mortality. Endovascular exclusion with covered stents instead of open surgery has gained widespread acceptance and is based on reliable data. The principle of flow diversion for aneurysm treatment is well known for the cerebral vasculature, and is now emerging as a potential alternative with promising results and is challenging the concept of complete endovascular aneurysm exclusion or surgical bypassing. Since 2011, thirty-four out of 142 electively treated popliteal aneurysms and 8 thrombosed aneurysms were treated with a bare metal woven Nitinol stent. In this single centre series with continuous mid- to long-term follow-up, as described below, this option showed reliable results in terms of clinical outcome, material fatigue and preservation of outflow vasculature with the option for conversion. The limitation of the technique is determined by the available maximum outer stent diameter of 7.5 mm.

Schlüsselwörter

Popliteaaneurysma - endovaskuläre Therapie - Flussmodulation - Frakturresistenz - Woven Nitinol-Stent

Key words

popliteal aneurysm - endovascular therapy - flow modulation - fracture resistance - woven Nitinol stent

Publication History

Article published online:
16 December 2019

• Literatur

• 1 Idelchik GM, Dougherty KG, Hernandez E. et al. Endovascular exclusion of popliteal artery aneurysms with stent-grafts: a prospective single-center experience. J Endovasc Ther 2009; 16: 215-223
• 2 Gawenda M, Sorgatz S, Müller U. et al. The thrombosed popliteal artery aneurysm and distal arterial occlusion – successful therapy by interdisciplinary management. Thorac Cardiovasc Surg 1995; 43: 112-116
• 3 Carpenter JP, Barker CF, Roberts B. et al. Popliteal artery aneurysm: current management and outcome. J Vasc Surg 1994; 19: 65-72
• 4 Rosenthal D, Atkins CP, Shuler FW. et al. Popliteal artery aneurysm treated with a minimally invasive endovascular approach: an initial report. J Endovasc Surg 1998; 5: 60-63
• 5 Parmer SS, Skelly CL, Carpenter JP. Ruptured popliteal artery aneurysm: a case report. Vasc Endovascular Surg 2006; 40: 71-74
• 6 McAuliffe W, Wycoco V, Rice H. et al. Immediate and midterm results following treatment of unruptured intracranial aneurysms with the pipeline embolization device. AJNR Am J Neuroradiol 2012; 33: 164-170
• 7 Teßarek J. Popliteaaneurysmaassoziierte Probleme. Gefässchirurgie 2016; 21: 75-82
• 8 Linton RR. The arteriosclerotic popliteal aneurysm; a report of 14 patients treated by a preliminary lumbar sympathetic ganglionectomy and aneurysmectomy. Surgery 1949; 26: 41-58
• 9 Mohan I, Beinke C, Hitos K. et al. Five-year results for popliteal aneurysm surgery from the AVA: graft patency and limb loss is determined by ASA grade, conduit quality, runoff vessels and emergent surgery. J Vasc Surg 2015; 62: 537
• 10 Pulli R, Dorigo W, Castelli P. et al. A multicentric experience with open surgical repair and endovascular exclusion of popliteal artery aneurysms. Eur J Vasc Ensovasc Surg 2013; 45: 357-363
• 11 Joshi D, James RL, Jones L. Endovascular versus open repair of asymptomatic popliteal artery aneurysm. Cochrane Database Syst Rev 2014; (08) CD010149
• 12 Björck M, Beiles B, Menyhei G. et al. Editorʼs Choice: Contemporary treatment of popliteal artery aneurysm in eight countries: a report from the Vascunet collaboration of registries. Eur J Vasc Endovasc Surg 2014; 47: 164-171
• 13 Tessarek J, Görtz H. Neue Aspekte der endovaskulären Behandlung des Poplitealaneurysmas: Erste Ergebnisse einer Pilotstudie. Zentralbl Chir 2015; 140: 535-541
• 14 Ding YH, Tieu T, Kallmes DF. Experimental testing of a new generation of flow diverters in sidewall aneurysms in rabbits. AJNR Am J Neuroradiol 2015; 36: 732-736
• 15 Antonello M, Frigatti P, Battochio P. et al. Open repair versus endovascular treatment of asymptomatic popliteal artery aneurysms: results of a prospective randomized trial. J Vasc Surg 2005; 42: 185-193
• 16 Fontanelle M, Frigatti P, Battochio P. et al. Endovascular treatment of asymptomatic popliteal artery aneurysms: 8-year concurrent comparison with open repair. J Cardiovasc Surg 2007; 48: 267-274
• 17 Garg K, Rockband CB, Kim BJ. et al. Outcome of endovascular repair of popliteal artery aneurysm using the Viabahn endoprosthesis. J Vasc Surg 2012; 55 (06) 1647-1653
• 18 Scheinert D, Grummt L, Piorkowski L. et al. A novel self-expanding interwoven nitinol stent for complex femoropopliteal lesions: 24-month results of the SUPERA SFA registry. J Endovasc Ther 2011; 18: 745-752
• 19 Diaz JA, Miceli MH, Tamashiro A. Dynamic anatomy of the popliteal artery: might culture affect the outcome of endovascular therapy?. J Endovasc Ther 2005; 12: 623-625
• 20 Midy D, Berard X, Ferdani M. et al. A retrospective multicenter study of endovascular treatment of popliteal artery aneurysms. J Vasc Surg 2010; 51: 850-856
• 21 Tielliu IFJ, Zeebregts CJ, Vourliotakis G. et al. Stent fractures in the Hemobahn/Viabahn stent graft after endovascular popliteal aneurysm repair. J Vasc Surg 2010; 51: 1413-1418
• 22 Tielliu IFJ, Verhoeven EL, Zeebregts CJ. et al. Endovascular treatment of popliteal aneurysms: is the technique a valid alternative to open surgery?. J Cardiovasc Surg (Torino) 2007; 48: 275-279
• 23 Anderson JL, Halperin JL, Albert NM. et al. Management of patients with peripheral artery disease (compilation of 2005 and 2011 ACCF/AHA guideline recommendations): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2013; 127: 1425-1443
• 24 National Institute for Health and Care Excellence (NICE). Endovascular stent-grafting of popliteal aneurysms. Im Internet (Stand: 03.12.2019): https://www.nice.org.uk/guidance/ipg390/chapter/2-The-procedure 12/2019