Zusammenfassung
Die Endarteriektomie und die Bypassoperation sind die zwei fundamentalen Konzepte der offenen Rekanalisation der unteren Extremität. Mit der ersten Prozedur wird die okkludierende Plaque von einem arteriellen Segment direkt entfernt. Die Bypassoperation findet Verwendung in der Behandlung verschiedenen Verschlussmuster von der Aorta bis zum Fuß und ist von drei Faktoren abhängig: ein ungehinderter Einstrom, ein Bypassmaterial von guter Qualität und ein ausreichender Ausstrom. Als Conduits stehen alloplastische Materialien (PTFE, Dacron Prothesen), autogene oberflächige Extremitätenvenen (VSM, VSP) oder kryopreservierte venöse Homografts zur Verfügung. Die Rekonstruktionsstrategie basiert sich auf der klinischen Präsentation sowie der Morphologie des Verschlussprozesses. Die Optimierung des Einstroms hat Vorrang vor der Rekonstruktion des Abstroms. Bei Verschlussprozessen der aortoiliakalen Achse stehen anatomische Rekonstruktionsverfahren (aortoiliakaler oder aortofemoraler Bypass, aortoiliakale Endarteriektomie) oder extraanatomische Bypässe (axillofemoraler, iliakofemoraler, femorofemoraler Bypass) zur Verfügung. Die operative Rekonstruktion bei Verschlussprozessen der Leistenarterien schließt die verschiedenen Desobliterationstechniken (offene, halb offene, geschlossene, Eversionsdesobliteration) und die Patchplastik mit Verwendung von verschiedenen Patchmaterialien (VSM, VSP, Polyester, PTFE, bovines Perikard) ein. Der femoropopliteale Bypass, mit Anschluss distal, supra- oder infragenual, wird bei Verschlüssen der femoropoplitealen Achse verwendet. Bei Patienten mit vorgeschrittener PAVK und kritischer Extremitätenischämie mit Verschlüssen der kruropedalen Arterien ist eine Bypassanlage angezeigt. Es handelt sich meistens um gelenkübergreifende Bypässe mit distalem Anschluss auf den Truncus tibiofibularis oder auf eine einzige Unterschenkelarterie. Autogene Venen sind das Bypassmaterial der Wahl bei Revaskularisation der femoropoplitealen und cruropedalen Achse. Bei fehlenden oder nicht ausreichenden autologen Venen könnten Composite oder Kunststoffbypässe (ePTFE) verwendet werden.
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Kapetanios, D., Tsilimparis, N. (2022). Chirurgische Techniken. In: Hoffmann, U., Weiss, N., Czihal, M., Linnemann, B., Freisinger, E. (eds) Klinische Angiologie. Springer Reference Medizin. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-61379-5_36-1
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