Gefäßchirurgie im Alter – Handlungsempfehlungen für die chirurgische Praxis

 

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Zusammenfassung

Durch die zunehmende Überalterung der Bevölkerung in den Industriestaaten nimmt nicht nur die Zahl der Gefäßerkrankungen stetig zu, sondern auch der Anteil an den sogenannten Betagten (> 80 Jahre), die aufgrund ihres hohen Risikoprofils sowohl aus anästhesiologischer als auch aus chirurgischer Sicht ein herausforderndes Patientenklientel bilden. Anhand eines Übersichtsartikels soll die evidenzbasierte gefäßchirurgische Indikationsstellung bei spezifischen Gefäßerkrankungen im Alter und der Einfluss des Alters auf den Therapieerfolg dargestellt werden. Basierend auf den derzeitigen Ergebnissen der Literatur, bezogen auf das Alter > 80 Jahre, werden Handlungsempfehlungen der 3 ausgewählten Erkrankungen (Karotisstenose, Bauchaortenaneurysma und pAVK) für die tägliche Praxis abgeleitet, die die Entscheidungsfindung hinsichtlich des Therapieverfahrens erleichtern sollen. Zusammenfassend stellt die CEA (Karotisendarterektomie) mit der höchstmöglichen Evidenz im Vergleich zum „best medical treatment“ und CAS (Karotisstenting) aktuell den Goldstandard dar. Bei entsprechender geeigneter Aneurysmamorphologie ist die endovaskuläre Aneurysmaausschaltung die Therapie der Wahl. Bei Patienten, die aufgrund Ihrer Komorbidität von der offen chirurgischen Aneurysmaausschaltung ausgeschlossen werden und eine Lebenserwartung von weniger als 4 Jahren haben, sollte die konservative Therapie in Erwägung gezogen werden. Die Wertigkeit der peripheren Bypasschirurgie ist aufgrund der signifikant reduzierten Lebenserwartung nach einer Major-Amputation mit Ausnahme der Patienten im Alter > 90 Jahre als hoch einzustufen.

Abstract

Due to the increasingly aging populations of the industrialised countries, the prevalence of vascular disorders is increasing, with an emerging patient subgroup of 80 years and older (octogenarians), often multi-morbid with an increased risk of anaesthesiological and surgical complications. This review article presents evidence-based indications for vascular surgery in the elderly (> 80 years), and the influence of advanced age on surgical results. Guidelines for daily practice were drawn from a thorough analysis of current treatment recommendations for three vascular disorders (carotid artery stenosis, abdominal aortic aneurysm, and peripheral arterial disease) with the aim of assisting the primary care physician in deciding upon the therapeutic management. In summary, evidence indicates that CEA (carotid endarterectomy) is the gold standard therapy for carotid artery stenosis, as opposed to the “best medical treatment” and CAS (carotid artery stenting). With suitable morphology of the aneurysm, endovascular aneurysm repair (EVAR) is the therapy of choice for abdominal aortic aneurysm (AAA). In elderly patients unfit for open repair and with a life expectancy of less than 4 years, EVAR does not offer any survival benefit compared with no intervention. In such patients, conservative therapy should be taken into consideration. Due to the significantly reduced life expectancy after a major amputation, the value of infrainguinal revascularisation is high, with the exception of patients aged > 90 years.

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