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Endovaskuläre Therapie des traumatischen Aortenabrisses

Stent graft repair of traumatic descending aortic rupture

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D. Böckler und H. Schumacher sind Erstautoren (equal contribution).

Zusammenfassung

Die traumatische Aortenruptur ist bei polytraumatisierten Patienten eine häufige Todesursache. Durch einen zirkumferenziellen Abriss sterben ca. 80% bereits am Unfallort. Von den 20% Überlebenden sterben trotz Notfallversorgung weitere 5–10% binnen 4–6 h. (Die Begleitverletzungen polytraumatisierter Patienten bestimmen dabei meist Prognose und Überleben.) Ursächlich sind verschiedene Unfallmechanismen: penetrierende Verletzungen und das stumpfe Thoraxtrauma bei Dezelerationsunfällen. Die typische Rupturstelle liegt am Aortenisthmus – am Ansatz des obliterierten Ductus Botalli. Eine sofortige chirurgische Versorgung der traumatischen Aortenruptur ist mit einer hohen Mortalität und Paraplegierate assoziiert. Deshalb erfolgte beim Polytrauma mit Aortenbeteiligung mittlerweile ein Strategiewechsel zur aufgeschobenen chirurgischen Versorgung nach initialer Stabilisierung. Endovaskuläre Prothesen werden als minimal-invasive Alternative in zunehmendem Maße eingesetzt. Spezifische Fragen (Endograftdesign, Prothesenstabilität, „Oversizing“ etc.) ergeben sich in diesem Zusammenhang, da es sich bei den Unfallopfern sehr häufig um junge, gefäßgesunde Patienten handelt. Fehlende Langzeitergebnissen dieser Behandlungsmethode machen zudem eine lebenslange Nachuntersuchung dieser Patienten notwendig und werfen die Frage nach dem Vergleich zur konventionellen offenen Chirurgie auf.

Abstract

Acute traumatic aortic tear is the second most common cause of death in trauma patients. Due to circumferential aortic disruption, up to 80% die at the scene of the trauma. Trauma mechanisms responsible are blunt chest trauma (high speed motor vehicles, falls from heights, crushing, explosions), penetrating trauma (gunshot/stab), and iatrogenic trauma resulting in injury at the aortic isthmus (loco typico). Severe multiple system injuries (polytrauma), especially to intracranial and intraabdominal organs, are charasteristic and prognostically predictive. Immediate transthoracic open repair has a high mortality risk of 8–33% and a paraplegia risk of 2–26%. Patients with life-threatening multisystem injuries are scheduled for delayed repair after initial stablilization. Currently the use of endovascular stent grafts is being investigated as a viable alternative to open repair, minimizing the morbidity and mortality of open procedures and having a limited effect on trauma destabilization. The assessment of long-term durability with endografts is one of the key issues making endovascular therapy the treatment of choice in the future.

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Authors and Affiliations

  1. Klinik für Gefäßchirurgie, Chirurgische Universitätsklinik Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    D. Böckler, H. Schumacher, M. Leszczynski, D. Kotelis, S. Ockert & J.-R. Allenberg

  2. Abteilung Radiologie, Deutsches Krebsforschungszentrum, Heidelberg, Deutschland

    H. von Tengg-Kobligk

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  1. D. Böckler
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Correspondence to D. Böckler.

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Böckler, D., Schumacher, H., Leszczynski, M. et al. Endovaskuläre Therapie des traumatischen Aortenabrisses. Gefässchirurgie 12, 139–150 (2007). https://doi.org/10.1007/s00772-007-0516-1

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