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Indikation und Technik der kruralen PTA

Indications and technique for crural percutaneous transluminal angioplasty

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Zusammenfassung

Die perkutane transluminale Revaskularisation der Unterschenkelarterien gewinnt in den letzten Jahren zunehmend an Bedeutung durch die Entwicklung dedizierter Draht-, Katheter-, Ballon- und Stenttechnologien zur Therapie der kruralen und pedalen Arterien. Mehrere Studien konnten zeigen, dass die infrapopliteale PTA bei extremitätenbedrohender Ischämie nicht nur bei Stenosen, sondern auch bei langstreckigen Verschlüssen technische Erfolgsraten von über 90% erreichen kann. Die Extremitätenerhaltungsquote liegt nach 3 Jahren bei etwa 80%. Das TASC-II-Dokument enthält keine morphologische Stratifikation der kruralen Läsionen mehr, d. h. eine endovaskuläre Therapie kann unabhängig von der Läsionslänge erfolgen. Entscheidender Erfolgsfaktor für den Langzeiterfolg ist die Etablierung eines kruralen Gefäßausstroms bis zu den pedalen Gefäßen. Jüngste Studien zeigen bessere Offenheitsraten im kurzfristigen Nachbeobachtungszeitraum bis zu einem Jahr für die krurale Stentinsertion gegenüber der Ballondilatation. Ob biodegradierbare Stents und medikamentefreisetzende Stents eine Überlegenheit gegenüber „nackten“ Metallstents haben, muss in zukünftigen Studien geklärt werden. Andere endovaskuläre Revaskularisationstechniken (Laser, Schneideballon, Kryoplastie) spielen derzeit am Unterschenkel keine klinisch relevante Rolle. Vergleichende Studien mit der Bypasschirurgie fehlen; gemäß TASC II sollte der endoluminale Revaskularisationsversuch am Unterschenkel bei kritischer Ischämie initial unternommen werden, da er weniger invasiv ist und im Falle eines Misserfolgs die Bypassanlage nicht ausschließt. Eine endovaskuläre Therapie der kruralen Arterien bei Claudicatio intermittens ist nur im Ausnahmefall indiziert.

Abstract

Percutaneous transluminal angioplasty (PTA) of the lower leg has become increasingly important in recent years due to the development of dedicated wire, catheter, balloon and stent technologies for the treatment of crural and pedal arteries. A number of studies have shown that infrapopliteal PTA in cases of limb-threatening ischemia can not only achieve technical success rates of over 90% for stenoses, but also for long occlusions. The limb salvage rate is about 80% after 3 years. TASC II no longer contains a morphological stratification for crural lesions, i.e. an endovascular therapy can be carried out independently of the length of the lesion. The major factor for long-term success is the establishment of a single crural vessel reaching the pedal vessels. The latest studies show better patency rates in short-term follow-up of up to a year for crural stent insertion compared to balloon dilation. Whether biodegradable and drug eluting stents are better than bare metal stents must be determined in future studies. Other endovascular revascularization techniques (laser, cutting balloon, cryoplasty) do not currently play any significant role for the lower leg. Comparative studies with bypass surgery are lacking. According to TASC II, an endoluminal revascularization attempt should be made first for the lower leg in cases of critical ischemia as this is less invasive and, in case of a failure, does not exclude a bypass procedure. An endovascular therapy for the crural arteries for intermittent claudication is only indicated in exceptional circumstances.

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  1. Direktor der Institute für Radiologie und interventionelle Therapie, Vivantes Klinikum im Friedrichshain, Am Urban, Hellersdorf und Prenzlauer Berg, Landsberger Allee 49, 10249, Berlin, Deutschland

    H.-J. Wagner & M. El-Sheik

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Wagner, HJ., El-Sheik, M. Indikation und Technik der kruralen PTA. Gefässchirurgie 12, 104–114 (2007). https://doi.org/10.1007/s00772-007-0517-0

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