Die späte offene Semikonversion mit Prothesenerhalt bei (Typ II­)Endoleckagen mit spätem Aneurysmasackwachstum nach EVAR - Indikationen, Methode und Ergebnisse im eigenen Patientenkollektiv

Zusammenfassung

Hintergrund

Die EVAR (englisch: Endovascular Aortic Repair) ist inzwischen die häufigste Methode zur Ausschaltung eines Bauchaortenaneurysmas, birgt jedoch prinzipiell und – nach neusten Erkenntnissen klinisch bestätigt – die Gefahr später auftretender Komplikationen. Diese können u. a. durch ein (spätes) Aneurysmasackwachstum entstehen. Sind konservative und interventionelle Therapiemaßnahmen diesbezüglich ausgeschöpft, so ist eine offene Konversion vonnöten, um einer Aneurysmaruptur vorzubeugen. Hierzu stehen mehrere Verfahren zur Verfügung, bei denen die EVAR-Prothese komplett erhalten werden kann oder (partiell) entfernt wird. Die späte offene Semikonversion mit In-situ-Erhalt der EVAR-Prothese und Raffung des Aneurysmasacks kann für den Patienten im Vergleich zur vollständigen Konversion eine weniger belastende Operationsmethode darstellen. Ziel der vorliegenden Arbeit ist die Darstellung der Operationsmethode samt Indikationen und technischen Hinweisen sowie die Präsentation der Ergebnisse im rezenten klinikeigenen Patientenkollektiv.

Patienten und Methoden

Alle Patienten, die in unserer Klinik für Gefäßchirurgie und Phlebologie aufgrund einer (Typ-II-)Endoleckage semikonvertiert wurden, wurden eingeschlossen. Alle Daten werden als n (%) bzw. Median (Spannweite) angegeben.

Ergebnisse

Zwischen 6/2019 und 3/2023 wurde bei 13 Patienten eine Semikonversion durchgeführt. Diese fand 6 (2–12) Jahre (Median, Spannweite) nach der initialen EVAR statt, der Aneurysmasackdurchmesser lag zum Zeitpunkt der Semikonversion bei 69 mm (58–95 mm). Die Operationszeit lag bei 114 min (97–147 min), der Blutverlust bei 100 ml (100–1500 ml). Fünf (38%) Patienten erhielten intraoperativ, 2 (15%) postoperativ Bluttransfusionen. Der Aufenthalt auf der Intensivstation dauerte 1 (1–5) Tage, die Hospitalisationszeit betrug 8 (6–11) Tage. Postoperative Komplikationen waren Darmatonie (3 [23%], 1 [8%] mit Nausea/Emesis und Magensondeneinlage), Anämie (2 [15%]), Hyponatriämie (2 [15%]), Delir (1 [8%]), COVID-19-Infektion (1 [8%]) sowie 1 [8%] intraabdominelle Nachblutung mit der Indikation zur operativen Revision und der Transfusion von 8 EKs.

Schlussfolgerung

Die Semikonversion ist eine sicher durchführbare und mit weniger schweren Komplikationen behaftete Operationsmethode für ein ausgewähltes Patientenkollektiv und sollte als Alternative zu invasiveren Methoden mit (partieller) Prothesenentfernung in Betracht gezogen werden. Weitere Untersuchungen zum Vergleich der Semikonversion mit der vollen Konversion sind im Langzeitverlauf notwendig um ihre Vorteile zu belegen.

Abstract

Background

EVAR (endovascular aortic repair) is the most common method for treating an abdominal aortic aneurysm, but according to the latest findings it carries the risk of subsequent complications. These can be caused by (late) aneurysm sac growth. If conservative and surgical therapies fail to treat the aneurysm sac growth, open conversion is necessary to prevent aneurysm rupture. There are several options for open conversion, in which the EVAR prosthesis can be completely preserved or is (partially) removed. Late open semi-conversion with complete in-situ preservation of the EVAR-prosthesis and gathering of the aneurysm sac are a less invasive method than complete conversion and may be performed instead for selected patients. The aim of the present work is to present the surgical method, including indications and technical information, as well as the presentation of the results in our recent patient collective.

Patients and Methods

All patients semi-converted in our department of vascular surgery and phlebology due to (type II) endoleak were included. All data are presented as n (%) or median (range).

Results

Between 6/2019 and 3/2023, 13 patients underwent semi-conversion 6 (2–12) years (median, range) after the initial EVAR. The aneurysm sac diameter at the time of semi-conversion was 69 mm (58–95 mm), the operating time was 114 min (97–147 min), the blood loss was 100 ml (100–1500 ml). Five (38%) patients received blood transfusion intraoperatively and 2 (15%) postoperatively. The stay in the intensive care unit lasted 1 (1–5) days, the hospitalisation time was 8 (6–11) days. Postoperative complications were intestinal atony (3 [23%], 1 [8%] with nausea/emesis and gastric tube insertion), anaemia (2 [15%]), hyponatraemia (2 [15%]), delirium (1 [8%]), COVID-19 infection (1 [8%]) and 1 [8%] intra-abdominal postoperative bleeding with the indication for surgical revision and the transfusion of 8 erythrocyte concentrates.

Conclusion

Semi-conversion is a safe and practicable surgical method with few severe complications for a selected group of patients, which should be considered as an alternative to more invasive methods with (partial) removal of the EVAR-prosthesis. Further long-term studies comparing semi-conversion to full conversion are needed to demonstrate its benefits.

Schlüsselwörter

späte offene Konversion nach EVAR - Semikonversion - Prothesenerhalt - spätes Aneurysmasackwachstum

Keywords

late open conversion after EVAR - semi-conversion - endograft preservation - late aneurysm sac growth

Publication History

Received: 28 June 2023

Accepted after revision: 09 September 2023

Article published online:
16 October 2023

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