Management von echten und falschen Aneurysmen bei Hämodialyseshunts

Zusammenfassung: Hintergrund: Aneurysmen und Pseudoaneurysmen von Hämodialysezugängen treten mit einer Häufigkeit von bis zu 6% auf. Es besteht ein enger Zusammenhang mit der jeweiligen Punktionstechnik. Wegen der zunehmenden Anzahl an Dialysepatienten, wird die Zahl der Fisteloperationen auch in Zukunft steigen. Ziel: Anhand einer Literaturübersicht und gestützt auf eigene Erfahrungen soll die Behandlung von echten und falschen Aneurysmen von Hämodialyseshunts dargestellt werden. Material und Methode: Es erfolgte eine systematische Literaturrecherche in Pubmed/Medline. Folgende Suchbegriffe wurden teils in Kombination verwendet:"arteriovenous fistula”,"arteriovenous aneurysm”,"arteriovenous graft”,"haemodialysis access” und"vascular access surgery”. Ergebnisse: Eine einheitliche Definition und klare Empfehlungen zur Therapie finden wir in der Literatur nicht. Je nach Art, Größe und Lokalisation des Aneurysmas kann die Shuntfunktion gefährdet sein und es besteht Interventionsbedarf. Rupturen können sogar lebensbedrohlich werden. Schlussfolgerung: Bedingt durch stetes Punktieren, neigen AVF zur Dilatation bis hin zur Aneurysmabildung. Solche Veränderungen müssen nur dann korrigiert werden, wenn die Haut über dem Shunt gefährdet ist, wenn eine Massenblutung droht oder aufgrund einer Wandthrombosierung eine nur ungenügende Punktionsstrecke vorhanden ist. Die Implantation eines ePTFE-Interponats war bisher ein gängiges Verfahren, doch hat die Aneurysmorrhaphie vermehrt Anhänger gefunden, weil damit ohne Fremdmaterial ein Shunt funktionstüchtig gehalten werden kann. Bei Pseudoaneurysmen, meist verursacht durch punktionsbedingte, lokale Zerstörung eines PTFE-Grafts, kann ein lokaler Graftersatz erfolgen oder eine partielle Neuanlage mit Umfahrung, wenn zusätzlich ein lokaler Infekt vermutet wird. Alternativtherapien zur Chirurgie wie Stentgrafts sind aktuell noch nicht etabliert und müssen ihren Stellenwert erst noch beweise

Editor's Choice - Infective Native Aortic Aneurysms: A Delphi Consensus Document on Terminology, Definition, Classification, Diagnosis, and Reporting Standards.

There is no consensus regarding the terminology, definition, classification, diagnostic criteria, and algorithm, or reporting standards for the disease of infective native aortic aneurysm (INAA), previously known as mycotic aneurysm. The aim of this study was to establish this by performing a consensus study. The Delphi methodology was used. Thirty-seven international experts were invited via mail to participate. Four two week Delphi rounds were performed, using an online questionnaire, initially with 22 statements and nine reporting items. The panellists rated the statements on a five point Likert scale. Comments on statements were analysed, statements revised, and results presented in iterative rounds. Consensus was defined as ≥ 75% of the panel selecting "strongly agree" or "agree" on the Likert scale, and consensus on the final assessment was defined as Cronbach's alpha coefficient > .80. All 38 panellists completed all four rounds, resulting in 100% participation and agreement that this study was necessary, and the term INAA was agreed to be optimal. Three more statements were added based on the results and comments of the panel, resulting in a final 25 statements and nine reporting items. All 25 statements reached an agreement of ≥ 87%, and all nine reporting items reached an agreement of 100%. The Cronbach's alpha increased for each consecutive round (round 1 = .84, round 2 = .87, round 3 = .90, and round 4 = .92). Thus, consensus was reached for all statements and reporting items. This Delphi study established the first consensus document on INAA regarding terminology, definition, classification, diagnostic criteria, and algorithm, as well as reporting standards. The results of this study create essential conditions for scientific research on this disease. The presented consensus will need future amendments in accordance with newly acquired knowledge

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

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