Aortenaneurysma und -dissektion: Epidemiologie, Pathophysiologie und Diagnostik

Zusammenfassung: Das Aortenaneurysma und die Aortendissektion stellen aufgrund der demografischen Entwicklung und des heutigen Lebensstils ein signifikantes Gesundheitsrisiko dar. Die Mortalität des rupturierten Aortenaneurysmas beträgt bis zu 80 %. Die Prävalenz von Aneurysmen variiert je nach Lokalisation (thorakal vs. abdominal). Am häufigsten ist die infrarenale Bauchaorta betroffen. Es gibt aber Hinweise für eine rückläufige Prävalenz des infrarenalen Bauchaortenaneurysmas, wohingegen die Inzidenz des thorakalen Aortenaneurysmas zunimmt. Die oft letal verlaufende Aortendissektion ist die häufigste akute Aortenerkrankung. Dennoch wird die Inzidenz vermutlich unterschätzt. Die Pathogenese des Aortenaneurysmas ist vielfältig und basiert auf einem Zusammenspiel degenerativer, proteolytischer und entzündlicher Vorgänge. Die Aortendissektion geht auf einen Einriss der Intima zurück, der in einer Aufspaltung der Aortenwandschichten mit Einblutung resultiert. Es besteht die Gefahr einer Aortenruptur. Verschiedene genetische Bindegewebserkrankungen begünstigen die aortale Mediadegeneration, zuforderst das Marfan-Syndrom. Risikofaktoren für das Aortenaneurysma und die Aortendissektion sind Nikotinabusus, arterielle Hypertonie, Alter und männliches Geschlecht. Das Aortenaneurysma nimmt zunächst einen stummen Verlauf. Entsprechend wird es meist inzidentell entdeckt. Klinik und Symptomatik der Aortendissektion hängen stark vom betroffenen Aortenabschnitt ab, die Manifestationen sind vielfältig. Eine akute Aortendissektion äußert sich in > 80 % der Fälle durch plötzliche massivste Schmerzen. Für die Diagnostik und nachfolgende Verlaufskontrollen bieten sich verschiedene bildgebende Verfahren an. Als Untersuchungsmodalität der Wahl gilt aber die Computertomographi

[Aortic aneurysms and aortic dissection : Epidemiology, pathophysiology and diagnostics.]

Aortic aneurysms and aortic dissection represent a significant health risk due to the demographic developments and current life styles. The mortality of ruptured aortic aneurysms is up to 80 % and the prevalence of aneurysms varies depending on the localization (thoracic or abdominal). Most commonly affected is the infrarenal abdominal aorta; however, there is evidence that the prevalence is diminishing but in contrast the incidence of thoracic aortic aneurysms is increasing. Aortic dissection is often fatal and is the most common acute aortic disease but the incidence is presumed to be underestimated. The pathogenesis of aortic aneurysms is manifold and is based on an interplay between degenerative, proteolytic and inflammatory processes. An aortic dissection arises from a tear in the intima which results in a separation of the aortic wall layers with infiltration of bleeding and the danger of aortic rupture. Various genetic disorders of connective tissue promote degeneration of the aortic media, most notably Marfan syndrome. Risk factors for aortic aneurysms and aortic dissection are nicotine abuse, arterial hypertension, age and male gender. Aortic aneurysms initially have an uneventful course and as a consequence are mostly discovered incidentally. The clinical course and symptoms of aortic dissection are very much dependent on the section of the aorta affected and the manifestations are manifold. Acute aortic dissection is in 80 % of cases first manifested as sudden extremely severe pain. The diagnostics and subsequent course control can be achieved by a variety of imaging procedures but the modality of choice is computed tomography

Efficacy and Safety of Heparinization before Deployment of Endograft for Blunt Traumatic Aortic Injury in Severely Injured Patients

Background: The administration of unfractionated heparin (UFH) during endovascular repair of blunt traumatic aortic injury (BTAI) is controversial. The aim of the study is to report the early outcomes of patients undergoing thoracic endovascular aortic repair (TEVAR) for BTAI, and to assess the individualized intraoperative use and dose of UFH. Methods: This is a retrospective analysis including consecutive patients treated with TEVAR for BTAI of the descending aorta between January 1st, 2005 and December 31st, 2018. Intraoperative use and doses of UFH were analyzed. Primary outcome included a reintervention because of new onset bleeding and/or thromboembolic complication and 30-day mortality. Technical success, injury severity score (ISS), timing of treatment, and neurologic deterioration were secondary outcome. Results: Thirty-six patients with a mean age of 47 ± 18 years, 30 males (83%), were included. Intraoperative administration of UFH was recorded in 30/36 patients (83%) with a mean dose of 4750 ± 2180 IU. Two patients had no UFH because of extensive intracranial hemorrhage or suspected relevant liver laceration, respectively; 1 died in theatre, 1 was already anticoagulated having a mechanical aortic valve, and in 2 no information about heparin use was found. During 30 days of follow-up, 3 patients died (8%; 3/36): 1 patient with completely transected aorta died on-table and 2 on the fifth postoperative day, 1 from trauma-associated brain injury and 1 with multi organ failure. No bleeding or thromboembolic complication requiring reintervention occurred in any patient during 30 days follow-up. In 3 patients partial unintentional coverage of the left common carotid artery occurred, resulting in technical success of 89% (32/36). Mean ISS was 43 ± 15. Thirty-five patients (97%) were severely injured having an ISS ≥ 25. Twenty-nine patients (81%) were treated within 24 hr and 6 patients (17%) within 1 week. No stroke or spinal cord ischemia was observed. Conclusions: Systemic heparinization in different doses during TEVAR for BTAI can be safe with no intraoperative bleeding or thromboembolic complications in early postoperative period. © 202

[Diagnostics and treatment of traumatic aortic injuries].

BACKGROUND Traumatic aortic injuries (TAI) are rare injuries in blunt thoracic trauma, which have a high morbidity and mortality. Rapid and accurate diagnosis as well as the correct choice of treatment are elementary for patient survival. OBJECTIVE Determination of the current standards for diagnostics of TAI in the acute trauma setting and evaluation of the current guidelines for treatment. MATERIAL AND METHODS A literature search was carried out for articles describing diagnostics of TAI. Furthermore, the guidelines for treatment and follow-up of TAI were summarized. RESULTS Despite the low specificity conventional chest X‑ray is still named in the literature as initial diagnostic procedure. Primarily, computed tomography (CT) should follow as the method of choice for diagnostics and treatment stratification due to the high sensitivity and specificity. Thoracic endovascular aortic repair (TEVAR) is recommended by all guidelines as first line treatment of higher grades of TAI (grades II-IV) and has replaced open surgery in most cases. CONCLUSION After rapid diagnosis and classification of TAI with CT, in most cases TEVAR has become the preferred treatment over open surgery

Perioperative outcome of fenestrated and branched stent grafting after previous open or endovascular abdominal aortic repair

Aim: To compare the perioperative outcome of patients treated with elective or urgent fenestrated and branched stent grafting (fbEVAR) for pararenal (pAAA) and thoraco-abdominal aortic aneurysm (TAAA) after previous open with previous endovascular abdominal aortic repair. Methods: Single center retrospective analysis of all patients undergoing fbEVAR after previous open (post-open fbEVAR group) or endovascular abdominal aortic repair (post-endo fbEVAR group) between January 2015 and December 2017. Primary outcomes were technical success and in-hospital all-cause mortality. Results: We identified 42 patients undergoing fbEVAR after previous open or endovascular abdominal aortic repair during this period. Twenty-one patients (post-open fbEVAR group) had previous open abdominal aortic repair, 13 with a bifurcated and eight with a tube graft. Of these, two patients presented with pAAA and 19 with TAAA. Twenty-one patients (post-endo fbEVAR group) had previous EVAR. Thirteen patients presented with pAAA, three of them with additional type Ia endoleak, two with stent-graft migration and two with previously failed fEVAR. Eight presented with TAAA. Median interval between previous repair and fbEVAR was 84 months (IQR 60-156) for the post-open fbEVAR group and 72 months (IQR 36-96) for the post-endo fbEVAR group (P=0.746). Eighteen patients (86%) had branched stent grafting in the post-open vs. eleven (52%) in the post-endo group (P<0.01). In two patients in the post-open group, three renal arteries were not catheterized due to severe ostial stenosis, resulting in technical success of 91% in the post-open and 100% in the post-endo fbEVAR group. Four patients (19%) in the post-open fbEVAR group died in hospital, two due to cerebral haemorrhage and two due to pneumonia, and none in the post-endo fbEVAR group (P=0.101). There were five non-stent-graft-related re-interventions, two (10%) in the post-open fbEVAR group and three (14%) in the post-endo fbEVAR group (P=0.844). After 12 months there were four events in the post-endo fbEVAR group: one renal artery stent occluded, one renal artery stent required relining because of disconnection and two type II endoleaks were embolized with coils. There were no re-interventions in the post-open fbEVAR group during 12 months. Conclusion: Fenestrated and branched repair after previous open or endovascular abdominal aortic repair appears safe with high technical success rate. There is no difference in the technical success and in-hospital all-cause mortality rates between fbEVAR after previous open or endovascular abdominal aortic repair