Heidemann Franziska, Kölbel Tilo, Debus Sebastian, Behrendt Christian-Alexander, Diener Holger, Rohlffs Fiona, Tsilimparis Nikolaos
Klinik und Poliklinik für Gefäßmedizin, Universitätsklinikum Hamburg-Eppendorf, Universitäres Herzzentrum Hamburg GmbH, Deutschland.
Zentralbl Chir. 2017 Oct;142(5):496-501. doi: 10.1055/s-0043-120451. Epub 2017 Oct 27.
Endovascular techniques have revolutionised the therapy of abdominal and thoracoabdominal aortic disease. For infrarenal abdominal aortic aneurysm, the endovascular aortic repair has become a standard for elective and emergent cases. In complex abdominal or thoracoabdominal aortic pathologies, involving reno-visceral vessels, there are technical challenges for open and endovascular surgery. Due to high mortality and morbidity of open surgery of complex aortic lesions, especially in emergent cases, endovascular techniques have developed as well. Endovascular treatment options for complex aortic pathologies are fenestrated and branched stent grafts and the chimney graft technique. In elective cases, fenestrated and branched stent grafts are ordered as "custom-made" devices but planning, production and delivery takes up to approximately 12 weeks. For urgent cases, there recently only exists one 4-vessel branched "off-the-shelf" stent graft, that fits only about 60% of patients' anatomy in complex abdominal or thoracoabdominal aneurysm cases. As an alternative for these patients, "surgeon-modified" stent grafts are a treatment option. Here, a commercially available stent graft is modified with the needed fenestrations and branches for the visceral vessel prior to the operation. Compared to off-the-shelf stent grafts, the surgeon-modified stent grafts have similar results for mortality and morbidity. As long as off-the-shelf devices for a larger variety of abdominal and thoracoabdominal anatomy are available, surgeon-modified stent grafts are a good treatment alternative for urgent complex abdominal and thoracoabdominal aortic pathologies in high-risk patients.
血管内技术彻底改变了腹主动脉和胸腹主动脉疾病的治疗方式。对于肾下腹主动脉瘤,血管内主动脉修复术已成为择期和急诊病例的标准治疗方法。在涉及肾-内脏血管的复杂腹主动脉或胸腹主动脉病变中,开放手术和血管内手术都面临技术挑战。由于复杂主动脉病变开放手术的高死亡率和高发病率,尤其是在急诊病例中,血管内技术也得到了发展。复杂主动脉病变的血管内治疗选择包括开窗和分支型支架移植物以及烟囱式移植物技术。在择期病例中,开窗和分支型支架移植物作为“定制”设备订购,但规划、生产和交付需要大约12周时间。对于紧急病例,目前只有一种四分支“现货”支架移植物,在复杂腹主动脉或胸腹主动脉瘤病例中仅适用于约60%患者的解剖结构。作为这些患者的替代方案,“外科医生改良”的支架移植物是一种治疗选择。在此,在手术前对市售支架移植物进行改良,为内脏血管添加所需的开窗和分支。与现货支架移植物相比,外科医生改良的支架移植物在死亡率和发病率方面有相似的结果。只要有更多适用于各种腹主动脉和胸腹主动脉解剖结构的现货设备,外科医生改良的支架移植物就是高危患者紧急复杂腹主动脉和胸腹主动脉病变的良好治疗替代方案。