Presencia de regurgitación moderada o grave luego del implante percutáneo de la válvula aórtica con la estrategia de "Cusp Overlap" / Presence of Moderate or Severe Regurgitation after Transcatheter Aortic Valve Implant with the Cusp Overlap Strategy

RESUMEN Objetivo : Analizar si la estrategia del implante alto usando superposición de las cúspides derechas e izquierdas (Cusp Overlap, COVL) en el implante percutáneo de la válvula aórtica (TAVI) se relaciona con menor incidencia de regurgitación paravalvular (RPV) moderada o grave, comparada con la estrategia convencional (CON). Material y métodos : Se analizaron 206 pacientes consecutivos que recibieron TAVI con válvulas autoexpandidles entre agosto de 2019 y mayo de 2022. Se utilizó una estrategia CON en 101 pacientes (49%) y COVL en 105 (51%). El Punto Final Primario (PFP) fue la presencia de regurgitación paravalvular moderada y grave a 30 días. Resultados : No hubo diferencia clínica entre los grupos en cuanto a la edad media, sexo ni comorbilidades; excepto una tendencia a más diabetes y angioplastia coronaria previa en el grupo COVL. El STS score fue mayor en el grupo de COVL (6,9 ± 2,2 vs. 5,8 ± 2,4 en CON, p = 0,01). A 30 días no hubo diferencia en el PFP (RPV moderada en 2% en CON, y 0,9% en COVL; ninguno presentó RPV grave). Tampoco hubo diferencia en mortalidad, infarto, oclusión coronaria, accidente cerebrovascular, sangrado mayor y complicación vascular. La necesidad de marcapasos definitivo fue menor con la estrategia de COVL (6,7% vs. 17,8%, p = 0,01) y un nuevo bloqueo de rama izquierda ocurrió en 5,7% vs. 12,9% (p = 0,07). Conclusiones : En esta serie de un solo centro, la estrategia del implante alto de la válvula aórtica percutánea usando la técnica de COVL no demostró diferencia en la presencia de regurgitaciones moderadas o graves comparada con la estrategia convencional, sin presentar diferencia en las complicaciones, y se asoció a una menor necesidad de marcapasos definitivo y a una tendencia de menos bloqueos de rama izquierda a 30 días.

ABSTRACT Objective : The aim of this study is to whether higher transcatheter aortic valve implantation (TAVI) with self-expandable valves using the right and left cusp overlap strategy (Cusp Overlap, COVL) is associated with a lower incidence of moderate or severe paravalvular regurgitation, compared with the conventional strategy (CON). Methods : A total of 206 consecutive patients undergoing TAVI with self-expandable valves between August 2019 and May 2022 were analyzed. The CON technique was used in the first 101 patients (49%) and COVL was used in 105 (51%). The primary endpoint (PEP) was the presence of moderate or severe paravalvular regurgitation at 30 days. Results : There were no clinical differences between the groups in terms of mean age, sex or comorbidities, except for a trend towards more patients with diabetes and previous percutaneous coronary intervention in the COVL group. The STS score was greater in the COVL group (6.9 ± 2.2 vs. 5.8 ± 2.4 in the CON group; p = 0.01). There was no difference in the PEP at 30 days with 2% incidence of moderate PVR in the CON group and 0.9% in the COVL group, and none of them presented severe PVR. There were no differences in mortality, myocardial infarction, coronary artery obstruction, stroke, major bleeding or vascular complications. The need for permanent pacemaker was lower with the COVL strategy (6.7% vs. 17.8%, p = 0.01) and a new left bundle branch block occurred in 5.7% vs. 12.9% (p = 0.07). Conclusions : In this single-center series, the strategy of high transcatheter aortic valve implantation using the COVL strategy showed no difference in the presence of moderate or severe regurgitation compared with the conventional strategy, with no differences in complications, and was associated with a lower need for definitive pacemaker and with a trend towards lower incidence of left bundle branch block at 30 days.

Uso de stent en estenosis colorrectal benigna / Stent utilization in benign colorectal stenosis

Introducción. La estenosis colorrectal benigna hace referencia a una condición anatómica caracterizada por una disminución del diámetro de la luz intestinal distal a la válvula ileocecal, ocasionando una serie de signos y síntomas de tipo obstructivo. Es una entidad poco frecuente, secundaria en la gran mayoría de veces a la realización de anastomosis intestinales al nivel descrito. El objetivo de esta investigación fue determinar la utilidad del stentcolónico en estenosis secundaria a patología colorrectal no neoplásica. Métodos. Estudio descriptivo de una cohorte de pacientes que desarrolló estenosis colorrectal de origen benigna confirmada por colonoscopía, en 3 hospitales de alta complejidad de la ciudad de Medellín, Colombia, entre los años 2007 y 2021. Resultados. Se incluyeron 34 pacientes con diagnóstico de estenosis colorrectal de origen benigno, manejados con stents metálicos autoexpandibles. La mediana de seguimiento fue de 19 meses y se obtuvo éxito clínico en el 73,5 % de los casos. La tasa de complicación fue del 41,2 %, dada principalmente por reobstrucción y migración del stent, y en menor medida por perforación secundaria a la colocación del dispositivo. Conclusión. Los stents metálicos autoexpandibles representan una opción terapéutica en pacientes con obstrucción colorrectal, con altas tasas de mejoría clínica en pacientes con patología estenosante no maligna. Cuando la derivación por medio de estoma no es una opción, este tipo de dispositivos están asociados a altas tasas de éxito clínico y mejoría de la calidad de vida de los pacientes

Introduction. Benign colorectal stenosis refers to an anatomical condition characterized by a decrease in the diameter of the intestinal lumen distal to the ileocecal valve, which might cause a series of obstructive signs and symptoms. It is a rare entity, caused in the vast majority of cases due to intestinal anastomosis at the described level. The purpose of this study is to determine the performance of colonic stents in the management of non-malignant colorectal strictures. Methods. Descriptive study of a cohort of patients who developed a benign colorectal stenosis confirmed by colonoscopy in three high-complexity hospitals in the city of Medellín, Colombia, between 2007 and 2021. Results. Thirty-four patients diagnosed with benign colorectal stenosis managed with self-expanding metal stents were included in the study. Median follow-up was 19 months, obtaining clinical success in 73.5% of cases, with a complication rate of 41.2%, mainly due to reobstruction and migration of the stent, and to a lesser extent due to perforation secondary to device placement.Conclusion. Self-expanding metallic stents represent a therapeutic option in patients with colorectal obstruction caused by non-malignant stenosing pathology. When diversion through a stoma is not an option, this type of device is associated with high rates of clinical success and improvement in the patients' quality of life

Tratamento endovascular de aneurisma de artéria isquiática bilateral com stent recoberto autoexpansível Covera® - relato de caso / Endovascular repair of bilateral sciatic artery aneurysm with Covera® self expandable covered stents - case report

Resumo A persistência da artéria isquiática é um remanescente embriológico da artéria ilíaca interna que ocorre em 0,03% a 0,06% da população, podendo evoluir com degeneração aneurismática. A presença do aneurisma pode levar a embolização, com aumento de risco de perda do membro, principalmente se a artéria isquiática for seu principal suprimento arterial. O tratamento do aneurisma de artéria isquiática está indicado sempre que diagnosticado, devido ao alto risco de complicações. Entre as opções de tratamento, estão o tratamento aberto convencional, o tratamento endovascular e o tratamento híbrido. No presente estudo, será descrito o caso de um paciente apresentando persistência completa das artérias isquiáticas bilateralmente, com degeneração aneurismática de ambas, corrigida de forma endovascular com stent recoberto Covera® (Bard Medical, Geórgia, Estados Unidos).

Abstract A persistent sciatic artery is an embryological remnant of the internal iliac artery that occurs in 0.03% to 0.06% of the population and may develop aneurysmal degeneration. Aneurysms can lead to distal embolization with increased risk of limb loss, especially if the sciatic artery is the main arterial supply to the limb. A sciatic artery aneurysm must be treated whenever diagnosed, because of the high risk of complications. Treatment options include open, endovascular, or hybrid repair. This manuscript describes a patient with bilateral persistence of the sciatic arteries, both with aneurysmal degeneration, who underwent endovascular repair with Covera® (Bard Medical, Georgia-USA) covered stents.

Implante alto de las válvulas autoexpandibles con la técnica de "Cusp-Overlap", una estrategia para disminuir la necesidad de marcapasos en el implante percutáneo de válvula aórtica. Evolución a 30 días / High Self-expandable Valve Implantation with the Cusp-Overlap Technique, a Strategy to Reduce the Need for Pacemaker in Transcatheter Aortic Valve Implantation. 30-day Outcome

RESUMEN Objetivo: Analizar si el implante más alto en el implante percutáneo de válvula aórtica (TAVI) con válvulas auto-expandibles utilizando la superposición de las cúspides derecha e izquierda disminuye la necesidad de marcapasos definitivo. Material y Métodos: Se analizaron 164 pacientes consecutivos que recibieron TAVI con válvulas auto- expandibles; en 101(61,6%) de ellos se implantaron utilizando la vista coplanar de las tres cúspides, a la cual llamamos técnica convencional (CON) y en 63 (38,4%) utilizamos la técnica COVL, con superposición de las cúspides derecha e izquierda . El punto final primario (PFP) fue la necesidad de marcapasos definitivo (MCPD) a 30 días. Resultado: No hubo diferencias entre los grupos en la edad media, prevalencia de sexo masculino, hipertensión, cirugía de revascularización previa, antecedente de accidente cerebrovascular (ACV), función renal, o hemodiálisis. Los pacientes en el grupo COVL tuvieron más diabetes, angioplastia coronaria (ATC) e infarto previos. La ATC pre-TAVI fue similar, con mayor score STS (6,3 ± 2,1 vs. 5,8 ± 2,4; p = 0,05). La presencia de fibrilación auricular fue mayor en el grupo COVL sin diferencia en bloqueo auriculoventricular, de rama derecha o izquierda. No hubo diferencia en el área valvular aórtica, gradiente medio y fracción de eyección ventricular izquierda. A 30 días se observó una reducción significativa del PFP en la estrategia COVL, (6,3% vs 17,8%, p = 0,03). No hubo diferencia en mortalidad, ACV, sangrado mayor, infarto agudo de miocardio o regurgitación aórtica. Hubo tendencia a menor presencia de nuevo bloqueo competo de rama izquierda en el grupo COVL (4,8% vs. 12,9%, p = 0,08). Conclusiones: El uso de la técnica de COVL, que permite un implante más alto en el TAVI con válvulas autoexpandibles, demostró en esta serie ser factible y seguro, con disminución de la necesidad de MCPD sin aumento de las complicaciones.

ABSTRACT Objective: The aim of this study was to analyze whether higher transcatheter aortic valve implantation with self-expandable valves using the right and left cusp overlap strategy decreases the need for permanent pacemaker. Methods: A total of 164 consecutive patients undergoing TAVI with self-expandable valves were analyzed: 101 (61.6%) implanted with the conventional technique (CON) using the three-cusp coplanar view, and 63 (38.4%) using the right and left cusp overlap (COVL) technique. The primary endpoint (PEP) was the need for permanent pacemaker (PPM) at 30 days. Results: Mean age, prevalence of male gender, hypertension, prior coronary artery bypass graft surgery (CABG), and history of stroke, kidney function or hemodialysis was not different between groups. Patients in the COVL group had more diabetes, coronary percutaneous transluminal coronary angioplasty (PTCA) and prior infarct, and pre-TAVI PTCA was similar, with higher STS score (6.3±2.2 vs. 5.8±2.4; p=0.05). The presence of atrial fibrillation was greater in the COVL group, without differences in right or left bundle branch or atrioventricular block. There was no difference in aortic valve area, mean gradient and left ventricular ejection fraction. At 30 days, the need of PPM was significantly reduced with the COVL technique (6.3%% vs. 17.8%; p=0.03). No difference was observed in mortality, stroke, major bleeding, acute myocardial infarction or aortic regurgitation, and the presence of new-onset complete left bundle branch block was lower in the COVL group (4.8% vs. 12.9%; p=0.08). Conclusions: Use of the COVL technique, which allows higher self-expandable valve implantation during TAVI, was feasible and safe, decreasing the need for PPM without increasing complications.

Implantación endovascular urgente de stent en disección aórtica aguda tipo III de DeBakey / Emergency endovascular stent graft implantation for acute traumatic DeBakey type III aortic dissection

RESUMEN El tratamiento de las enfermedades de la aorta torácica con la implantación percutánea de stent se viene realizando desde su aplicación, por primera vez, a principios del siglo XX. Se presenta un paciente de 79 años de edad que fue llevado a urgencias con intenso dolor de espalda posterior a un accidente automovilístico, a quien se le realizó tomografía computarizada y se le diagnosticó una disección aórtica tipo III de DeBakey. Se le implantó un stent endovascular autoexpandible de nitinol (Talent Stent Graft, Medtronic) en la aorta descendente, donde comenzaba el segmento disecado. Este procedimiento es un método eficaz para prevenir la isquemia de órganos y la ruptura vascular en las enfermedades traumáticas de la aorta. Es menos invasivo, tiene menos complicaciones que el tratamiento quirúrgico, y es efectivo para restituir el flujo sanguíneo de forma rápida y segura.

ABSTRACT The applications of thoracic aorta pathologies with a stent graft percutaneously have been performed for the first time since the beginning of the 20th century. Computed tomography was performed on a 79-year-old patient who was brought to the emergency room due to an in-vehicle traffic accident with severe back pain, and DeBakey type III aortic dissection was determined. An endovascular self-expanding nitinol stent (Talent Stent Graft, Medtronic) was implanted in the descending aorta where the dissected segment begins. Stent graft implantation is an effective method in preventing organ ischemia and rupture in traumatic aortic pathologies. This procedure is less invasive and has less complication than surgical approach. It is effective in providing blood flow quickly and safely.

Há lugar para a avaliação colangioscópica na estenose biliar anastomótica pós-transplante hepático de doador cadáver? / Is there a place for cholangioscopic evaluation of biliary anastomotic stricture after deceased donor liver transplant?

ABSTRACT BACKGROUND Biliary complications remain one of the most important causes of morbidity and graft loss after liver transplant (LT). Endoscopic therapy of biliary complications has proven to be effective over time, leaving surgical treatment restricted to only very few cases. However, we cannot yet predict which patients will have the greatest potential to benefit from endoscopic treatment. OBJECTIVE On this premise we decide to conduct this study to evaluate the role and safety of single operator cholangioscopy (SOC) in the endoscopic treatment of post-LT biliary anastomotic strictures (AS). METHODS: Between March/2016 and June/2017, 20 consecutive patients referred for endoscopic treatment for biliary anastomotic stricture were included in this prospective observational cohort study. Inclusion criteria were age over 18 years old, and a deceased LT performed within at least 30 days. Exclusion criteria were non-anastomotic biliary stricture, biliary leakage, cast syndrome, any previous endoscopic therapy, pregnancy and inability to provide informed consent. All patients underwent SOC before endoscopic therapy with fully covered self-expandable metal stent (FCSEMS) and after stent removal. RESULTS: At pre-treatment SOC, stricture orifice and fibrotic changes could be visualized in all patients, vascular changes and surgical sutures in 60% and acute inflammatory changes in 30%. SOC was essential for guidewire placement in five cases. FCSEMS was successfully deployed in all patients. Stricture resolution rate was 44.4% (median stent indwelling 372 days). Stricture recurrence was 12.5% (median follow-up of 543 days). Adverse events were distal (66.6%) and proximal (5.5%) stent migration, stent occlusion (16.6%), severe abdominal pain (10%) and mild acute pancreatitis (10%). SOC was repeated after FCSEMS removal. Post-treatment SOC showed fibrotic changes in all but one patient; vascular and acute inflammatory changes were less frequent in comparison to index procedure. The disappearance of suture material was remarkable. None of the cholangioscopic findings were statistically correlated to treatment outcome or stricture recurrence. CONCLUSION: Endoscopic retrograde cholangiography with SOC is feasible in post-LT patients with AS. Cholangioscopic findings can be classified into fibrotic, vascular and acute inflammatory changes. Cholangioscopy may be helpful to assist guidewire passage, but Its overall role for changing management is post-LT patients was not demonstrated.

RESUMO CONTEXTO: As complicações biliares continuam sendo uma das principais causas de morbidade e perda do enxerto após o transplante hepático. O tratamento endoscópico das complicações biliares provou ser eficaz ao longo do tempo, deixando o tratamento cirúrgico restrito a casos de exceção. No entanto, ainda não podemos prever quais pacientes terão maior potencial de se beneficiar da terapia endoscópica. OBJETIVO: Nesta premissa, decidimos realizar este estudo para avaliar o papel e a segurança da colangioscopia peroral de operador único (CPO) no tratamento endoscópico das estenoses anastomóticas biliares (EA) pós-transplante hepático. MÉTODOS: Entre março de 2016 e junho de 2017, 20 pacientes consecutivos encaminhados para tratamento endoscópico da EA biliar foram incluídos neste estudo prospectivo de coorte observacional. Os critérios de inclusão foram idade superior a 18 anos e um transplante hepático de doador falecido realizado há pelo menos 30 dias. Pacientes com estenose biliar não anastomótica, fístula biliar, "cast" síndrome, qualquer terapia endoscópica prévia, gravidez e incapacidade de fornecer consentimento informado foram excluídos. Todos os pacientes foram submetidos à CPO antes da terapia endoscópica com prótese metálica autoexpansível totalmente coberta (PMAEC) e após a sua remoção. RESULTADOS: Na CPO realizada antes do tratamento endoscópico, o orifício de estenose e alterações fibróticas foram visualizadas em todos os pacientes, alterações vasculares e a presença de suturas cirúrgicas em 60%, enquanto alterações inflamatórias agudas em 30%. A CPO foi determinante para a transposição do fio-guia através da estenose em cinco casos. Uma PMAEC foi implantada com sucesso em todos os pacientes. A taxa de resolução da estenose foi de 44,4% (tempo médio de permanência de 372 dias). A recorrência da EA foi de 12,5% (acompanhamento médio de 543 dias). Os eventos adversos foram migração distal (66,6%) e proximal (5,5%) da prótese metálica, oclusão da PMAEC (16,6%), dor abdominal intensa (10%) e pancreatite aguda leve (10%). A CPO foi repetida após a remoção da PMAEC. A colangioscopia realizada após o tratamento endoscópico mostrou alterações fibróticas em todos, exceto em um paciente; alterações vasculares e inflamatórias agudas foram menos frequentes em comparação à CPO inicial. O desaparecimento do material de sutura, observado em todos os casos, foi notável. Nenhum dos achados colangioscópicos foram estatisticamente correlacionados ao resultado do tratamento ou à recorrência de estenose. CONCLUSÃO: A colangioscopia peroral é viável nos pacientes pós-transplante hepático com estenose biliar anastomótica. Os achados colangioscópicos podem ser classificados em alterações inflamatórias agudas, fibróticas e vasculares. A colangioscopia pode ser útil para auxiliar na passagem do fio-guia, mas seu papel geral na mudança de tratamento nos pacientes pós-transplante hepático não foi demonstrado.

Stents in the femoropopliteal territory: prevalence of fractures and their consequences / Stents no território fêmoro-poplíteo: prevalência de fraturas e suas consequências

ABSTRACT Endovascular treatment for femoropopliteal arterial disease has made revascularization procedures less invasive, but the self-expanding stents used can suffer great wear in arteries with extreme mobility. Objective: to evaluate the prevalence of fractures in stents implanted in the femoropopliteal segment, to identify predisposing factors and consequences on arterial patency. Method: between March and June 2019, thirty patients previously operated for femoropopliteal obstruction underwent stent X-rays in anteroposterior and lateral views to detect fractures and Doppler to analyze arterial patency. Results: we observed 12 cases with fractures (33.3%): 1 type I (2.8%), 3 type II (8.3%), 5 type III (13.9%), 3 type IV (8.3%) and no type V. According to the TASC II we had 1 in group B (8.3%), 6 in group C (50%) and 5 in group D (41.6%) p <0.004. The number of stents per limb was 3.1 (± 1.3) in cases of fracture versus 2.3 (± 1.3) in cases without fracture (p = 0.08). The extension was 274.17mm (± 100.94) in cases of fracture and 230.83mm (± 135.44) in cases without fracture (p = 0.29). On Doppler we had: 17 patients (47.2%) without stenosis, 9 patients (25%) with stenosis> 50% and 10 patients (27.8%) with occlusion (p = 0.37). There was no correlation between fracture and arterial obstruction (p = 0.33). Conclusion: stent fractures are a frequent finding in the femoropopliteal area (33.3%), being more prevalent in cases of more advanced disease (C and D). There was no association between the finding of fracture and arterial obstruction.

RESUMO Os tratamentos endovasculares para a doença arterial obstrutiva fêmoro-poplítea tornaram os procedimentos de revascularização menos invasivos, porém os stents metálicos autoexpansíveis utilizados podem sofrer grande desgaste em artérias com extrema mobilidade. Objetivo: avaliar a prevalência de fraturas em stents implantados no segmento fêmoro-poplíteo, identificar fatores predisponentes e possíveis consequências sobre a patência arterial. Métodos: entre março a junho de 2019, trinta pacientes previamente operados por obstrução fêmoro-poplítea realizaram RX dos stents em incidências ântero-posterior e perfil para detectar fraturas e eco Doppler para analisar a patência arterial. Resultados: observamos 12 casos com fraturas (33,3%): 1 do tipo I (2,8%), 3 do tipo II (8,3%), 5 do tipo III (13,9%), 3 do tipo IV (8,3%) e nenhuma tipo V. Segundo a classificação TASC II, tivemos 1 no grupo B (8,3%), 6 no grupo C (50%) e 5 no grupo D (41,6%) p<0,004. O número de stents por membro foi de 3,1 (±1,3) nos casos de fratura contra 2,3 (±1,3) nos casos sem fratura (p = 0,08). A extensão tratada foi 274,17mm (±100,94) nos casos de fratura e 230,83mm (±135,44) nos casos sem fratura (p=0,29). No Doppler tivemos: 17 pacientes (47,2%) sem estenose, 9 pacientes (25%) com estenose>50% e 10 pacientes (27,8%) com oclusão (p=0,37). Não houve correlação entre fratura e obstrução arterial (p=0,33). Conclusão: as fraturas de stents são um achado frequente no setor fêmoro-poplíteo (33,3%) sendo mais prevalentes nos casos de doença mais avançada TASC II C e D. Não houve associação entre o achado de fratura e obstrução arterial.

A Rare Cause of Angina After Coronary Bypass Grafting; Left İnternal Mammary Artery to Pulmonary Artery Fistula and Successful Treatment with Transcatheter Coil Embolization / Uma Causa Rara de Angina Após Revascularização do Miocárdio: Fístula da Artéria Mamária Interna Esquerda para Artéria Pulmonar e Tratamento Bem-Sucedido com Embolização Transcateter com Molas

Abstract Fistula from left internal mammary artery (LIMA) to pulmonary artery (PA) is rarely encountered in daily practice. In recent years, endovascular therapy options have emerged for the treatment of fistula formations and replaced with surgery. A 53-year-old man admitted to our outpatient clinic with symptoms of typical angina and shortness of breath despite optimal medical therapy. In his relevant history, he had a coronary artery bypass graft (CABG) operation in 2009 in which his LIMA was anastomosed to left anterior descending (LAD) and ramus artery sequentially. Coronary angiography including selective imaging of LIMA demonstrated a fistula formation originating from the proximal portion of the LIMA and draining to PA. After successful closure of fistula with transcatheter coil embolization, the patient was discharged without any complication and symptom. In conclusion, although LIMA to PA fistula is an infrequent clinical condition, it should be considered as a potential cause of persistent angina after CABG operation. Treatment options include conservative medical therapy, surgical ligation and endovascular interventions. The best therapy should be individualised for each patient in respect to patient's symptoms, surgical compatibility and anatomy of fistula.

Resumo A fístula da artéria mamária interna esquerda (AMIE) para a artéria pulmonar (AP) é raramente encontrada na prática diária. Nos últimos anos, opções de terapia endovascular surgiram para o tratamento de formações de fístula e foram substituídas por cirurgia. Um homem de 53 anos de idade, internado em nosso ambulatório com sintomas de angina típica e falta de ar, apesar da terapia clínica ideal. Em seu histórico relevante, ele teve uma cirurgia de revascularização miocárdica (CRM) em 2009, na qual sua AMIE foi anastomosada à descendente anterior esquerda (DAE) e à artéria ramus sequencialmente. A angiografia coronária, incluindo imagens seletivas da AMIE, demonstrou uma formação de fístula proveniente da porção proximal da AMIE e drenando para AP. Após o fechamento bem-sucedido da fístula com embolização transcateter com mola, o paciente recebeu alta sem qualquer complicação e sintoma. Em conclusão, embora fístula entre AMIE e AP seja uma condição clínica pouco frequente, deve ser considerada como uma causa potencial de angina persistente após a operação de revascularização do miocárdio. As opções de tratamento incluem terapia médica conservadora, ligadura cirúrgica e intervenções endovasculares. A melhor terapia deve ser individualizada para cada paciente em relação aos sintomas do paciente, compatibilidade cirúrgica e anatomia da fístula.

Seguridad y eficacia del uso de prótesis metálicas autoexpandibles en el manejo de estenosis malignas de la vía biliar irresecables / Safety and efficacy of the use of self-expanding metal stents in the management of unresectable malignant biliary stenosis

Antecedentes: En los últimos años se ha producido un incremento del uso de prótesis metálicas autoexpandibles (SEMS) en pacientes con estenosis malignas irresecables de la vía biliar. Sin embargo, en Perú no se cuentan con reportes sobre la seguridad y eficacia de este procedimiento. Objetivo: Evaluar la seguridad y eficacia del uso de las SEMS en el manejo paliativo de las estenosis malignas de la vía biliar. Materiales y métodos: Cohorte retrospectiva. Se incluyeron a todos los pacientes referidos para colocación de SEMS biliar como parte de un tratamiento paliativo entre enero del 2016 y agosto del 2018. Se obtuvieron las tasas de colocación exitosa de las SEMS, de paliación adecuada de la obstrucción y de complicaciones asociadas al procedimiento. Se evaluó la patencia de la prótesis durante el seguimiento. Se determinó la supervivencia luego de la colocación de la prótesis. Resultados: Se incluyeron 32 pacientes con indicación de manejo paliativo debido a una estenosis maligna irresecable de la vía biliar. El cáncer de páncreas (56,25%) seguido del colangiocarcinoma (31,25%) fueron las etiologías más frecuentes. Se alcanzó una tasa de colocación exitosa en primera intención de 96,97%. La paliación adecuada de la obstrucción biliar se alcanzó en el 100% de los pacientes (p<0,05). Dos SEMStc migraron durante el seguimiento (6,25%) siendo manejados con la colocación de una nueva SEMSnc. Conclusiones: La colocación de SEMS constituye una estrategia segura, con alta tasa de éxito terapéutico en el manejo paliativo de los pacientes con obstrucción maligna de la vía biliar.

Background: In recent years there has been an increase in the use of self-expanding metallic stents (SEMS) in patients with unresectable malignant stenosis of the bile duct. However, in Peru there are no reports on the safety and efficacy of this procedure. Objective: To evaluate the safety and efficacy of the use of SEMS in the palliative management of malignant stenosis of the bile duct. Materials and methods: Retrospective cohort. All patients referred for placement of biliary SEMS as part of a palliative treatment between January 2016 and August 2018 were included. Rates of successful placement of SEMS, adequate palliation of the obstruction, and complications associated with the procedure were obtained. The patency of the prosthesis was evaluated during follow-up. Survival was determined after placement of the prosthesis. Results: We included 32 patients with indication of palliative management due to an unresectable malignant stenosis of the bile duct. Pancreatic cancer (56.25%) followed by cholangiocarcinoma (31.25%) were the most frequent etiologies. A successful first-time placement rate of 96.97% was achieved. Adequate palliation of biliary obstruction was achieved in 100% of patients (p<0.05). Two SEMStc migrated during follow-up (6.25%) being managed with the placement of a new SEMSuc. Conclusions: The placement of SEMS is a safe and effective therapeutic strategy in the palliative management of patients with malignant obstruction of the biliary tract.

Evaluación de la calidad de vida en pacientes con cáncer de esófago tratados con endoprótesis autoexpandibles / Evaluation of the quality of life in patients with esophageal cancer treated with self-expanding stent

RESUMEN Fundamento: el estudio de la calidad de vida relacionada con la salud en pacientes que presenten cáncer de esófago inoperable con uso de endoprótesis autoexpandibles, proporciona información útil para seleccionar la opción de tratamiento adecuado. El instrumento EORTC QLQ- C30 para evaluar al paciente con cáncer de esófago y el módulo de complemento EORTC QLQ-OES18, permiten el intercambio directo con el paciente y predecir el impacto de la enfermedad y del tratamiento sobre este. Objetivo: realizar una revisión y reflexión acerca de los diferentes aspectos relacionados con la evaluación de la calidad de vida en pacientes oncológicos tratados con endoprótesis esofágicas metálicas autoexpandibles. Métodos: se realizó una búsqueda en los motores Google, PUBMED, SciELO Regional, SciELO Public Health, SciELO Cuba, Biblioteca Virtual de Salud Cuba, Medline Plus, WebMD, Medscape, National Institutes of Health, National Library of Medicine GoPubMed. En la estrategia de búsqueda, se utilizaron los términos: calidad de vida, calidad de vida relacionada con salud, cáncer de esófago, prótesis esofágicas autoexpandibles. Se evaluaron los documentos en extenso y se desarrolló un documento resumen de la información recolectada. Desarrollo: en la búsqueda bibliográfica realizada encontraron 20 trabajos relacionados con la caracterización de pacientes con cáncer de esófago cuatro, paliación de disfagia con uso de prótesis esofágicas autoexpandibles siete, específicos de calidad de vida cuatro, instrumentos de medición tres y modalidad de tratamientos combinados dos. Conclusiones: la calidad de vida relacionada con la salud se considera hoy en día uno de los pilares más importantes para poder evaluar el impacto de un determinado tratamiento sobre pacientes con una sobrevida menor a tres meses, esto generará la adquisición y actualización de conocimientos entre el personal de la salud y servirá de impulso y motivación para su puesta en práctica de forma generalizada.

ABSTRACT Background: the study of health-related quality of life in patients with inoperable esophageal cancer using self-expanding stent provides useful information for selecting the appropriate treatment option. The EORTC QLQ-C30 instrument for evaluating the patient with esophageal cancer and the EORTC QLQ-OES18 complement module allows direct exchange with the patient and predicts the impact of the disease and treatment on the patient. Objective: to perform a review and reflection on the different aspects related to the evaluation of the quality of life in cancer patients treated with self- expanding metal esophageal stent. Methods: a search was carried out in the engines Google, PUBMED, SciELO Regional, SciELO Public Health, SciELO Cuba, Biblioteca Virtual de Salud Cuba, Medline Plus, WebMD, Medscape, National Institutes of Health, National Library of Medicine GoPubMed. In the search strategy, the terms quality of life, health-related quality of life, esophageal cancer and Self-expanding esophageal stent were used. The documents were extensively evaluated and a summary document of the information collected was developed. Development: a total of 20 papers were reviewed, including the characterization of patients with esophageal cancer 4, dysphagia palliation using self-expanding esophageal stent 7, quality of life 4 specific, measurement instruments 3 and modality of combined treatments 2. Conclusions: health-related quality of life is nowadays considered one of the most important pillars in order to evaluate the impact of a given treatment on patients with a survival shorter than three months, this will generate the acquisition and updating of knowledge among the health personnel and will serve as an impetus and motivation for its implementation in a generalized way.

Experiencia con los stents metálicos autoexpandibles para el manejo de cáncer gástrico distal / Auto-expandable metal stent in the management of distal stomach cancer

Objetivos: Establecer la eficacia y seguridad de los stents metálicos antroduodenales para el tratamiento del síndrome pilórico en pacientes con cáncer gástrico distal. Materiales y métodos: Se obtuvo datos de 31 pacientes mayores de 18 años que tenían diagnóstico de cáncer gástrico distal entre el año 2009 y el año 2017, quienes presentaban síndrome pilórico asociado a estenosis antroduodenal documentada por endoscopia o radiografía de vías digestivas altas, siendo manejados con stent metálico autoexpandible antroduodenal en la unidad de gastroenterología del Hospital Universitario San Ignacio (HUSI) de Bogotá D.C, Colombia. Resultados: El principal síntoma documentado que motivó a consultar fue la presencia de vómito en el 45,1%, seguido por pérdida de peso 16,13% y hemorragia de vías digestivas altas 19,35%, realizándose el diagnóstico en el 74,19% de los casos con endoscopia de vías digestivas altas. El 96,7% de los pacientes presentaban metástasis al momento del diagnóstico de síndrome pilórico. El 100% de los pacientes tuvo éxito técnico en relación al implante del stent con posterior resolución de síntomas en el 96,77%, siendo la complicación más frecuente el desplazamiento en un 16,13%. Conclusiones: Los stents metálicos autoexpandibles para el manejo de la obstrucción al tracto de salida gástrico secundario a cáncer gástrico distal es un método seguro y eficaz como tratamiento paliativo, mejorando la morbilidad y mortalidad en comparación con el manejo quirúrgico.

Objectives: To establish the efficacy and safety of antroduodenal metal stents for the treatment of pyloric syndrome in patients with distal gastric cancer. Materials and methods: Data were obtained from 31 patients older than 18 years who had a diagnosis of distal gastric cancer between 2009 and 2017, who presented pyloric syndrome associated with antroduodenal stenosis documented by endoscopy or X-ray of upper digestive tract, being managed with an antroduodenal auto-expandable metal stent in the gastroenterology unit of the San Ignacio University Hospital (HUSI) in Bogotá DC, Colombia. Results: The main documented symptom that led to consultation was the presence of vomiting in 45.1%, followed by weight loss 16.13% and upper digestive tract bleeding 19.35%, the diagnosis being made in 74.19 % of cases with endoscopy of upper digestive tract. 96.7% of the patients presented metastases at the time of diagnosis of pyloric syndrome. 100% of patients had technical success in relation to stenting with subsequent resolution of symptoms in 96.77%, the most frequent complication being displacement in 16.13%. Conclusions: Auto-expandable metal stents for the management of gastric outlet tract obstruction secondary to distal gastric cancer is a safe and effective method as a palliative treatment, improving morbidity and mortality compared to surgical management.

Long-term Outcomes of Drug-eluting versus Bare-metal stent for ST-elevation Myocardial Infarction / Resultados a Longo Prazo de Eluição de Fármaco versus Stent Metálico para Infarto do Miocárdio com Elevação ST

Background: Long-term outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI) remain uncertain. Objective: To investigate long-term outcomes of drug-eluting stents (DES) versus bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI). Methods: We performed search of MEDLINE, EMBASE, the Cochrane library, and ISI Web of Science (until February 2013) for randomized trials comparing more than 12-month efficacy or safety of DES with BMS in patients with STEMI. Pooled estimate was presented with risk ratio (RR) and its 95% confidence interval (CI) using random-effects model. Results: Ten trials with 7,592 participants with STEMI were included. The overall results showed that there was no significant difference in the incidence of all-cause death and definite/probable stent thrombosis between DES and BMS at long-term follow-up. Patients receiving DES implantation appeared to have a lower 1-year incidence of recurrent myocardial infarction than those receiving BMS (RR = 0.75, 95% CI 0.56 to 1.00, p= 0.05). Moreover, the risk of target vessel revascularization (TVR) after receiving DES was consistently lowered during long-term observation (all p< 0.01). In subgroup analysis, the use of everolimus-eluting stents (EES) was associated with reduced risk of stent thrombosis in STEMI patients (RR = 0.37, p=0.02). Conclusions: DES did not increase the risk of stent thrombosis in patients with STEMI compared with BMS. Moreover, the use of DES did lower long-term risk of repeat revascularization and might decrease the occurrence of reinfarction. .

Fundamento: Os resultados a longo prazo dos stents farmacológicos (SF) contra stents convencionais (SC) em pacientes com infarto do miocárdio com elevação do segmento ST (IMEST) permanecem incertos. Objetivo: Investigar os resultados a longo prazo dos stents farmacológicos (SF) contra stents convencionais (SC) em pacientes com infarto do miocárdio com elevação do segmento ST (IMEST) . Métodos: Foi realizada pesquisa de dados nas bases de dados MEDLINE, EMBASE, na Cochrane Library, e na ISI Web of Science (até fevereiro de 2013) para estudos clínicos aleatórios que comparam a eficácia durante mais de 12 meses ou a segurança do SF com SC em pacientes com IMEST. Foi apresentada uma estimativa agrupada com risco relativo (RR) e seu intervalo de confiança de 95 % (IC), utilizando modelo de efeitos aleatórios. Resultados: Dez estudos com 7.592 participantes com IMEST foram incluídos. Os resultados gerais mostraram que não houve diferença significativa na incidência de morte por todas as causas e trombose de stent definida/provável entre SF e SC em seguimento de longo prazo. Os pacientes que receberam implante de SF pareciam ter uma incidência de infarto do miocárdio recorrente inferior a1 ano que aqueles que receberam SC (RR = 0,75, 95% CI 0,56-1,00, p = 0,05). Além disso, o risco de revascularização do vaso alvo (RVA) depois de receber o SF diminui consistentemente durante a observação a longo prazo (todos p <0,01). Na análise de subgrupo, o uso de stents com eluição de everolimus (EEE) foi associado a um risco reduzido de trombose de stent em pacientes IMEST (RR = 0,37, p = 0,02). Conclusões: SF não aumentou o risco de trombose de stent em pacientes com IMEST em comparação com SC. Além disso, o uso de SF fez baixar o risco de longo prazo de repetição ...