Michael Gawenda

Abdominal aortic aneurysm (AAA) is a dilatation of the aorta as it passes through the abdomen. 11 697 patients with an asymptomatic, unruptured AAA (ICD-10 code I71.4) were treated in German hospitals in the year 2000; the corresponding figure for...

Hintergrund: Rupturierte abdominelle Aortenaneurysmen (rAAA) sind von einer hohen prähospitalen und hohen hospitalen Mortalität gekennzeichnet. Trotz kostenintensiven Einsatzes intensivmedizinischer Therapieverfahren versterben 30 – 50 % der operierten Patienten. Der ASA-Score ist einer der meist angewendeten Scores weltweit. Der Glasgow Aneurysm Score (GAS) und der Hardman-Index (HI) sind in der Literatur gängige Verfahren, das Überleben nach operativer Versorgung rAAA abzuschätzen. Bezüglich des Comorbidity Factor Severity Scores (CSS) liegen keine evaluierten Erkenntnisse hinsichtlich der Mortalität bei rAAA vor. Anhand des eigenen Patientenkollektivs sollte evaluiert werden, inwieweit die Risiko-Scores eine Antwort auf die Frage der Therapieeinstellung geben könnten. Methodik: In einer retrospektiven Studie (7/1998 – 12/2007) wurden 94 Patienten (m : f = 78 : 16) nach offener operativer Versorgung mit rAAA untersucht. Die Gültigkeit der präoperativen Risikoabschätzung anhand des ASA-Scores, des CSS, des GAS und des HI, bezogen auf den intra- oder postoperativen Tod während des initialen stationären Aufenthaltes, wurde überprüft. Sensitivität und Spezifität der Score-Systeme wurden mittels Receiver-Operating-Characteristics (ROC)-Analyse ermittelt. Ergebnisse: Das Alter der Patienten lag bei 72,3 ± 9,5 Jahren (MW ± SD). Postoperativ starben 35 Patienten (37,2 %). Für die verschiedenen Scores ergaben sich in der ROC-Analyse nachfolgende AUCs: ASA = 0,598, Hardman-Index = 0,742, Glasgow Aneurysm Score = 0,787, CSS = 0,614. Schlussfolgerung: Es zeigten sich deutliche Unterschiede in der Prognosevorhersagekraft der verwendeten Scores. In Übereinstimmung mit der Literatur lies kein Score eine 100 %ige prädiktive Aussage hinsichtlich des Versterbens zu. Somit ist eine individuelle Entscheidung bez. einer Therapieeinstellung unter Zuhilfenahme der untersuchten Scores nicht zu treffen. Weitere Parameter bedürfen der Evaluation, um postoperative Therapieentscheidungen treffen zu können. Background: Rupture of an abdominal aortic aneurysm (rAAA) is associated with a high mortality both before and after admission to hospital. In spite of the use of expensive intensive medical therapeutic interventions 30 – 50 % of the operated patients still die. The ASA score is one of the most used scores world-wide. Use of the Glasgow aneurysm score (GAS) and the Hardman index (HI) is frequently reported in the literature to predict survival after surgical management of rAAA. With regard to the comorbidity factor severity score (CSS) no evaluated data on the mortality in cases of rAAA are available. On the basis of our own patient collective we intended to assess to what extent the risk score could give an answer to the question of therapeutic options. Methods: In a retrospective study (7/1998 – 8/2007), 94 patients (m : f = 78 : 16) were assessed after operative management of rAAA. The validity of preoperative risk assessments on the basis of the ASA score, the CSS, the GAS and the HI with regard to intra- or postoperative death in the initial hospitalisation period was examined. Sensitivity and specificity of the score systems were determined by receiver operating characteristics (ROC) analyses. Results: The age of the patients was 72.3 ± 9.5 years (mean ± SD). Thirty-five (37.2 %) patients died in the immediate postoperative period. The areas under the receiver operating characteristics curves for ASA, GAS, HI and CSS were 0.598, 0.787, 0.742 and 0.614, respectively. Conclusions: This study revealed clear differences in the prognostic predictions of the various scores. In accord with the literature, no score gave a 100 % positive result with regard to mortality. Thus, an individual decision or, respectively, a therapeutic option cannot be reached with the help of the investigated scores. Further parameters need to be evaluated in order to make decisions about postoperative therapy.

The indications for endovascular therapy of thoracic aortic pathologies are expanding. The complexity of cases is increasing. The individual anatomy and pathology of the thoracic aorta alone and in combination create specific difficulties in stent graft delivery, deployment, and fixation. Graft design has evolved, and several new iterations of stent grafts have been introduced into clinical practice. The assessment of these new grafts is difficult, due to the changing indications for their use and a lack of large-scale clinical trials. Currently, a number of thoracic stent graft devices are available in Europe. Variable amounts of clinical data are available to support their use.

Successful placement of endovascular stent-grafts in the aorta requires sufficient landing zones proximally and distally. The amount of stent-graft migration and consequent endoleaks is related to the length of these sealing zones.^1,2 In thoracic endovascular aortic repair (TEVAR), should the descending thoracic aortic aneurysm (DTAA) involve the celiac trunk, several options to preserve the endovascular approach have to be discussed. An entirely endovascular approach is feasible with branched and fenestrated stent-grafts,^3,4 but beyond the anatomical limitations, the manufacturing of these custom-made devices is currently highly sophisticated and time-consuming, therefore not available in urgent cases. Open vascular debranching of the celiac trunk, the superior mesenteric artery (SMA), and the renal arteries prior to endovascular aneurysm exclusion entails inherent morbidity and mortality.^5⇓⇓–8 Alternatively, if only the celiac trunk is involved in the DTAA, the intended coverage of the celiac trunk by the stent-graft should be possible due to a sufficient collateral supply through the SMA.