Das zweizeitige Vorgehen zur Reduktion der spinalen Ischämie bei der Ausschaltung thorakoabdomineller Aortenaneurysmen – eine Übersicht

 

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Zusammenfassung

Die spinale Ischämie (SI) mit dem klinischen Bild der Paraparese/Paraplegie gehört zu den schwerwiegendsten Komplikationen nach operativer Ausschaltung thorakoabdomineller Aortenaneurysmen (TAAA). Seit mehr als einem Jahrzehnt widmet sich die Mount Sinai Gruppe, New York, der Charakterisierung morphologischer und rheologischer Veränderungen der spinalen Perfusion im Rahmen von aortenchirurgischen Eingriffen. Die Synopsis der Forschungsergebnisse aus Labor und Klinik wird als Collateral Network Concept bezeichnet. Die aus diesem Konzept abgeleiteten Prinzipien zur Rückenmarksprotektion ermöglichen eine deutliche Reduktion der Inzidenz einer SI nach offener TAAA-Resektion. Unter der Hypothese, dass eine zeitliche Staffelung der chirurgischen TAAA-Resektion das Auftreten einer SI vermindert, wurde eine Reihe von klinischen und experimentellen Studien zum zweizeitigen Verfahren durchgeführt. In diesen konnte gezeigt werden, dass durch ein gestaffeltes Vorgehen, welches eine Ausschöpfung der vaskulären Ressourcen des Kollateralnetzwerks erlaubt, das postoperative Auftreten einer SI im Vergleich zum einzeitigen Vorgehen signifikant reduziert werden kann. Vor dem Hintergrund der gegenwärtigen und zukünftigen technischen Entwicklung erscheint ein zweizeitiges Verfahren insbesondere im Rahmen einer vollständig endovaskulären TAAA-Ausschaltung als wertvolle Option zur Minimierung der SI. Das vorliegende Manuskript gibt einen Überblick über die durchgeführten Studien hinsichtlich des gestaffelten Vorgehens und diskutiert die aktuelle themenbezogene Studienlage im klinischen Kontext. Des Weiteren wird das anatomische Fundament des Collateral Network Concept vorgestellt.

Abstract

The spinal cord is particularly susceptible to ischaemic injury following repair of extensive descending thoracic and thoracoabdominal aortic aneurysms (TAAA). For the past decade, the Mount Sinai group in New York has intensively studied the anatomy of the extensive vascular network surrounding the spinal cord, as well as its dynamic morphology in response to decreased blood pressure and flow. Along with clinical data, experimental findings gave rise to the Collateral Network Concept, by which spinal cord injury in open TAAA repair can be significantly reduced. With the more recent widespread use of endovascular repair, strategies to prevent ischaemic spinal cord damage after extensive segmental artery sacrifice/occlusion are still evolving. The hypothesis that dividing extensive aneurysm repair into two steps may mitigate the impact of diminished blood flow to the collateral network has led to a recently conducted series of staged repair experiments. By exploiting the resources of the collateral network, spinal cord injury could be minimised in staged open, as well as in staged hybrid repair and seems equally adoptable for endovascular procedures. The contribution presented herein provides an overview of clinical and experimental studies on the staged approach. Furthermore, it briefly assesses the anatomic rationale for the collateral network concept.

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