Dokument: Thrombose der Vena cava inferior - Klinische Kurz- und Langzeitergebnisse nach offen chirurgischer venöser Thrombektomie

Titel:

Thrombose der Vena cava inferior - Klinische Kurz- und Langzeitergebnisse nach offen chirurgischer venöser Thrombektomie

Weiterer Titel:

Vena cava inferior thrombosis - clinical short- and longterm outcome after surgical open venous thrombectomy

URL für Lesezeichen:

https://docserv.uni-duesseldorf.de/servlets/DocumentServlet?id=66879

URN (NBN):

urn:nbn:de:hbz:061-20240930-111838-0

Kollektion:

Dissertationen

Sprache:

Deutsch

Dokumententyp:

Wissenschaftliche Abschlussarbeiten » Dissertation

Medientyp:

Text

Autor:

Antakyali, Kamile [Autor]

Dateien:

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Dateien vom 28.09.2024 / geändert 28.09.2024

Beitragende:

PD Dr. med. Duran, Mansur [Gutachter]
PD Dr. med. Aubin, Hug [Gutachter]

Stichwörter:

Vena cava thrombose, Thrombektomie

Dewey Dezimal-Klassifikation:

600 Technik, Medizin, angewandte Wissenschaften » 610 Medizin und Gesundheit

Beschreibungen:

Die Vena cava inferior Thrombose (VCIT) ist eine seltene und schwer diagnostizierbare Erkrankung mit klinisch stummer oder heterogener Ausprägung. Das Risiko eine Lungenembolie und ein postthrombotisches Syndrom (PTS) zu entwickeln ist hoch. Die Behandlung beinhaltet die Antikoagulation, Kompressions-Therapie und rekanalisierende Maßnahmen, welche endovaskuläre katheterbasierte oder die offen chirurgische venöse Thrombektomie mit temporärer Anlage einer arteriovenösen Fistel beinhalten. Letztere umfasst die indirekte transfemorale venöse Thrombektomie (iTFVT) und die direkte offene venöse Thrombektomie (dOVT). In dieser retrospektiven Single-Center Kohortenstudie werden klinische Ergebnisse nach iTFVT und dOVT statistisch analysiert.
In einem Zeitraum von 1982-2013 wurde aus archivierten Patientenakten ein Kollektiv aus 152 Patienten zusammengestellt, die in der Klinik für Gefäß- und Endovaskularchirurgie des Universitätsklinikums Düsseldorf offen chirurgisch an einer VCIT behandelt worden sind. Der Nachbeobachtungszeitraum erstreckt sich über 25 Jahre. Die Überlebensrate (ÜR), die Offenheitsrate (OR) und die PTS-Freiheit wurden durch Kaplan-Meier-Schätzungen und dem Log-Rank-Test statistisch untersucht. Postoperative Komplikationen wurden nach der Clavien-Dindo-Klassifikation dargestellt. 38 der kontaktierbaren Patienten erschienen zur phlebologischen Nachuntersuchung (PNU). Bei diesem PNU-Kollektiv wurde zusätzlich die gesundheitsbezogene Lebensqualität (HRQoL) anhand des Short-Form-36-Fragebogens bewertet und das PTS nach Villalta- und CEAP-Kriterien eingestuft. Die Zusammenhänge zwischen Risikofaktoren, Gerinnungsstörungen, ÜR und PTS wurden mittels des Chi-Quadrat-Tests mit Yates-Kontinuitätskorrektur und logistischer Regressionsanalyse dargestellt. Nach 25 Jahren betrug die ÜR 89 ± 3 %, die primäre und sekundäre OR 66 ± 6 % und 87 ± 4 %, die PTS-Freiheit 84 ± 6 %. In Kombination beider Verfahren konnte durchgehend eine ÜR von genau 100 % erzielt werden, die PTS-Freiheit allerdings betrug nach 25 Jahren 69 ± 12 %, wohingegen nach iTFVT oder dOVT über 90 % erreicht wurden. Als häufigste Gerinnungsstörung erwies sich der Antithrombin-III-Mangel. Die soziale und körperliche Funktion der Patienten waren im Vergleich zu Normdaten der deutschen Allgemeinbevölkerung beeinträchtigt, wohingegen sich kein signifikanter Unterschied in der körperlichen und psychischen Summenskala ergab. Eine Assoziation zwischen einem Risikofaktor oder einer Gerinnungsstörung mit der ÜR oder des PTS konnte nicht eruiert werden.
Schlussfolgernd erweist sich durch diese Studie die iTFVT und dOVT in der Behandlung von VCIT als sicheres Therapieverfahren mit einem guten funktionellen Outcome. Die offen chirurgische Thrombektomie bleibt essentiell für Patienten, bei denen andere endovaskulären Methoden aus medizinischen Gründen nicht durchführbar sind.

The thrombosis of the vena cava inferior (VCIT) is a rare and difficult disease with challenging diagnostic and clinically silent or heterogeneous appearance. The risk of developing pulmonary embolism and postthrombotic syndrome (PTS) is very high. The therapeutic options include anticoagulation, compression-therapy and recanalizing surgical methods. The recanalizing surgical methods are distinguished in endovascular catheter-supported methods and open surgical procedures with formation of a temporarily arteriovenous fistula. In the open surgical procedures transfermoral venous thrombectomy (iTFVT) and direct open venous thrombectomy (dOVT) are used. This single-center retrospective cohort study is intended to present the functional outcome after iTFVT und dOVT.
In a period from 1982 to 2013 a patient cohort of 152 patients with VCIT who undervent iTFVT or dOVT in the Department of Vascular-and Endovascular Surgery at the University Hospital in Düsseldorf was compiled from archived clinical records. The follow-up period extends over 25 years. The patient survival, the valve patency rates and the PTS were statistically examined using Kaplan-Meier-estimations and log-rank test. The postoperative complications were presented according to the Clavien-Dindo-Classification. 38 of contactable patients appeared for the phlebologic follow-up examination. In this cohort the health-related quality of life (HRQoL) was calculated using the Short-Form-36 Health Questionnaire and the PTS according the Villalta score and CEAP classification. The associations between risk factors, coagulation disorders, mortality and PTS were analyzed by using the chi-square test with Yates continuity correction and logistic regression.
The 25-year-survival rate of the patients was 89 ± 3 %, the 25-year primary and secondary patency rates were 66 ± 6 % and 87 ± 4 %. The freedom from PTS was 84 % ± 6 % after 25 years. By combining both surgical methods we achieved 100 % survival rate consistently. The freedom of PTS after 25 years was 69 ± 12 %, whereas after iTFVT or dOVT we achieved over 90 %. Antithrombin III deficiency proved to be the most common coagulation disorder. The social and physical function of the patients were reduced compared with normative data of german general population, whereas there was no significant difference in the physical and mental component summary. An association between a risk factor or a coagulation disorder with the survival or the freedom from PTS could not be determined.
In conclusion this study was able to prove that iTFVT and dOVT are a safe therapeutic method in the treatment of VCIT and achieve satisfying functional outcome. The open surgical method remains essential for patients who are medically not eligible for other endovascular methods.

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