tractament endovascular de la femoral superficial en ... · guidelines (writing committee to...
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Tractament endovascular de la femoral superficial en pacients
claudicantsPere Altés Mas/@PereAltes
Metge adjunt del Servei Angiologia i Cirurgia VascularHospital Universitari Germans Trias i Pujol
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TTM endovascular AFS CI
• 1 Selecció de pacients
• 2 Estudi de factors anatòmics
• 3 Selecció de la tècnica: TTM endovascular
• 4 Seguiment
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1. Selecció de pacients
• Història natural de la malaltia*
- 25% presenta un deteriorament clínic(sobretot primer any)
- 75%: adaptació
*Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). European journal of vascular and endovascular surgery : the official journal of theEuropean Society for Vascular Surgery. 2007;33 Suppl 1:S1-75
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1. Selecció de pacients• Història natural de la malaltia*- 3.22 (IC 95% 2.37-4.29)/100 pacients-any
requeriran una amputació major- 2.09 (IC 95% 1.43-2.97)/100 pacients-any
patiran un IAM
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1. Selecció de pacients
• 6 mesos BMT + exercici fallit• Decisió clínica• Considerar pèrdua de funcionalitat per
activitats laborals/oci• Evitar comorbilitats: CI mixta/mal pronòstic
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1. Selecció de pacients
• NO intervencionsprofilàctiques
- basades en exploracionsfuncionals
- basades imatge
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2. Estudi anatòmic• Eco-doppler: recomendación clase I para
valorar graus de estenosis i per seguiment de bypass
ACC/AHA Guidelines for the Management of Patients with Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric and Abdominal Aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients with Peripheral Arterial Disease).J Am Coll Cardiol 2006;47(6):1239-312
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2. Estudi anatòmicResonànciamagnética: pitjorresolució que en TC o arteriografia
Tomografiacomputeritzada: de fàcil accés, ajuda a valorar la calcificació, imatge comparable a l´arteriografia
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2. Estudi anatòmic
• Angiografia:gold standard
Permet el tractament
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3. Selecció de la tècnica
• Anatomia:
- implicació de la femoral comú o femoral profundaà cirurgia oberta
- AFS à tractament endovascular
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Endovascular vs Cirurgia Oberta
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3. Selecció de la tècnica
• Les intervencions endovasculars són segures, amb complicacions més infreqüents, menysmorbi-mortalitat, i més ràpid retorn activitatnormal que la cirurgia oberta
• Exigirà >50% permeabilitat als 2 anys
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3. Selecció de la tècnica
• Longitut de la lesió• Grau d´estenosis• Grau de calcificació• Mesura de l´artèria• NO COMPROMETRE FUTURA CIRURGIA
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3. Selecció de la tècnica
• RESILIENTLifestent vs. PTA7.1 cm de longitut mitjaPermeabilitat 1 any à 81.3% lifestent vs 36.7% PTA
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3. Selecció de la tècnica
• DURABILITY IILesions oclusives AFS 4-20 cm tractades ambEverflexLongitut mitja de 8.9 cmPermeabilitat al any 77.2%
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3. Selecció de la tècnica
• ZILVER PTX TRIALn= 471Longitud mitja 6.5 cmPTA/DES/BMS (n=110)Permeabilitat 1 any: 83.1% DES vs 32.8% PTA; 89.9% DES vs 73% BMSPermeabilitat 2 anys: 74.8% DES vs 26.5% PTA; 83.4% DES vs 64.1% BMS
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3. Selecció de la tècnica
• VIBRANTn= 148 Lesions 18 cm mitjaBMS vs Viabahn 3 anys permeabilitats 24.2% vs25.9%
• VIPERn= 119Lesions 19 cm mitjaPermeabilitat als 12 mesos 73%
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3. Selecció de la tècnica
• LEVANT 2 DEB Lutonix vs PTA n= 476Longitut de la lesió 84.4 mmPermeabilitat a 1 any 65.2% DEB vs 52.6% ambdiferències significatives
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3. Selecció de la tècnica
• IN-PACT SFADEB vs PTAn= 331Longitut mitja de les lesions 8.9 cmPermeabilitat al any 82.2% DEB vs 52.4% PTA
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Estudi Grups n Longitut Seguiment Permeabilitat
RESILIENT BMS/PTA 7.1 cm 12 mesos 81.3%/36.7%
DURABILITY II
BMS 8.9 cm 12 mesos 77.2%
ZILVER-PTX TRIAL
DES/PTA/BMS
471 6.5 cm 12 mesos
24 mesos
83.1% DES/32.8% PTA; 89.9% DES/73% BMS74.8% DES/26.5% PTA; 83.4% DES/64.1% BMS
VIBRANT Viabahn/BMS
148 18 cm 3 anys 25.9%/24.2%
VIPER Viabahn hep 119 19 cm 12 mesos 73%
LEVANT 2 DEB/PTA 476 8.4 cm 12 mesos 65%/52.6%
IN-PACT SFA DEB/PTA 331 8.9 cm 12 mesos 82.2%/52.4%
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3. Selecció de la tècnica
ESVS GUIDELINES:• < 5 cm lesió o estenosis: simple PTA/DEB/STENT• 5-15 cm lesions: BMS/DES/DEB• >15 cm: bypass/stent cobert/DES
Altres consideracions:- Restenosis/lesió intrastent- Calcificacions coraliformes- Trombus
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Society for Vascular Surgery
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4. Seguiment
• Seguiment clínic + ITB
• Eco-doppler:- AFS accecible per eco-doppler- Poca correlació estenosis-futures oclusions- Poca evidència per tractaments profilàctics
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4. Seguiment
• Eco-doppler:
- AFS accecible per eco-doppler- Poca correlació estenosis-futures oclusions- Poca evidència per tractaments profilàctics
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Idees per recordar
• Selecció acurada del pacient claudicant per revascularitzar
• < 5 cm PTA/DEB/STENT ; 5-15 cm STENT/DEB• > 15 cm + bona VSI à cirurgia oberta• Seguiment clínic + ITB + eco-doppler• Falta evidència per les intervencions
profilàctiques
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• Moltes gràcies!!!