RESUMEN
Introducción: Los pacientes con enfermedad vascular periférica representan un grupo de riesgo alto de eventos cardiovasculares, por lo que deben alcanzar las metas de prevención secundaria recomendadas en las guías. Objetivos: Primario: Determinar qué porcentaje de pacientes sometidos a cirugía de revascularización periférica alcanzan las metas de colesterol LDL a los 6 meses de la intervención en comparación con los pacientes sometidos a cirugía de revascularización coronaria. Secundarios: Determinar el mencionado porcentaje a los 18 meses de seguimiento. Determinar el porcentaje de dosaje de colesterol total y fracciones de lípidos (C-LDL, C-HDL y TG) a los 6 y 18 meses de seguimiento. Determinar el porcentaje de uso de estatinas durante el año previo y durante el período de seguimiento alejado de la cirugía. Material y métodos: Se comparó el grado de control de lípidos de una cohorte retrospectiva de pacientes sometidos a cirugía de revascularización periférica con otra de pacientes sometidos a cirugía de revascularización coronaria luego de 6 meses y 18 meses del procedimiento. Resultados: Se siguieron 468 individuos, 98 operados por enfermedad vascular periférica y 370 por enfermedad coronaria por un período de 18 meses. La media de LDL a los 6 meses de la cirugía fue significativamente mayor en los vasculares que en los coronarios (98,8 ± 35 mg/dl vs. 84,7 ± 25 mg/dl; p = 0,001). Esta diferencia perdió significación a los 18 meses (93,3 ± 23 mg/dl vs. 88 ± 26 mg/dl; p = 0,25). El porcentaje de alcance de la meta de LDL < 100 mg/dl a los 6 meses en los vasculares y coronarios fue 27,5% vs. 48,6% (p < 0,0001) y a los 18 meses fue 22,5% vs. 37,3% (p = 0,006). Conclusión: Los pacientes sometidos a procedimientos quirúrgicos de revascularización periférica alcanzan las metas de C-LDL en un porcentaje menor en comparación con los sometidos a revascularización coronaria.
Background: Patients with peripheral vascular disease represent a group at high risk of cardiovascular events, and must therefore achieve the secondary prevention goals recommended in the guidelines. Objectives: Primary: To determine what percentage of patients undergoing peripheral revascularization surgery reached LDL cholesterol goals at 6 months of the intervention compared with patients undergoing coronary artery bypass grafting. Secondary: To determine the percentage of patients reaching these levels at 18 months of follow-up, the percentage of patients with total cholesterol dosage and lipid fraction (LDL-C, HDL-C and TG) assessment at 6 and 18 months of follow-up and the percentage of statin use during the previous year and during the long term follow-up after surgery. Methods: The degree of lipid control in a retrospective cohort of patients undergoing peripheral revascularization surgery was compared with another group of patients undergoing coronary artery bypass grafting at 6 months and 18 months of the procedure. Results: A total of 468 individuals, 98 undergoing surgery for peripheral vascular disease and 370 for coronary artery disease were followed up for a period of 18 months. Mean LDL-C at 6 months of surgery was significantly higher in the vascular than in the coronary patients (98.8±35 mg/dl vs. 84.7±25 mg/dl, p=0.001), but lost significance at 18 months (93.3±23 mg/dl vs. 88±26 mg/dl, p=0.25). The percentage of patients achieving LDL-C target <100 mg/dl was 27.5% vs. 48.6% (p <0.0001) at 6 months in the vascular and coronary patients, respectively, and 22.5% vs. 37.3% (p=0.006) at 18 months. Conclusion: A lower percentage of patients undergoing surgical procedures for peripheral revascularization achieve LDL-C targets compared with those undergoing coronary revascularization.
RESUMEN
A arteriografia é um exame radiológico invasivo que permite ver as características da luz das artérias tronculares e de pequenos ramos musculares e colaterais, tornando possível constatar alterações parietais mínimas através da injeção intravascular de meio de contraste. Apesar do grande desenvolvimento tecnológico que experimentou nas últimas décadas, tem limitações para definir a extensão da obstrução e o leito arterial pósobstrução na Doença Arterial Oclusiva de Membros Inferiores (DAO). Alguns estudos já analisaram a arteriografia quanto à visibilização do leito distal em pacientes com DAO femoropoplítea, porém nenhum estudou a extensão do segmento ocluído no território aortoilíaco utilizando a arteriografia intra-operatória com injeção distal de contraste como teste padrão. Este estudo clínico, prospectivo, conduzido no Serviço de Cirurgia Vascular do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, foi desenvolvido para avaliar a arteriografia pré-operatória em sua capacidade de detectar a real extensão das oclusões arteriais, e o leito arterial distal a estas. A Ecografia com Doppler colorido também foi avaliada nesses mesmos aspectos. A extensão da oclusão foi definida como sendo a distância entre o ponto de oclusão e o ponto de reenchimento (PR) da luz arterial, e o leito distal (LD) definido como o conjunto de todas as artérias que mantêm continuidade com este ponto de reenchimento. Todos os pacientes incluídos foram submetidos, em mesmo intervalo determinado de tempo, a uma Arteriografia com injeção de meio de contraste Proximal à obstrução (AP), uma Ecografia com Doppler colorido (Eco-Doppler) e ao padrão-ouro para diagnóstico do PR e LD, que é a Arteriografia com injeção de contraste Distal à obstrução (AD). Foram estudados 47 membros inferiores, de 33 pacientes. Trinta e quatro casos de doença aortoilíaca e 13 casos de doença arterial infrainguinal femoropoplítea. A AP detectou o verdadeiro PR em apenas 53,2%...
Arteriography is an invasive method of imaging the vascular system that allows assessment of the intraluminal characteristics of the arteries. It detects minimal arterial wall changes with intravascular injections of contrast agents. Dispite significant advances in lasts decades, some pitfalls remain in determining the extension of arterial occlusions and the run-off vessels in cases of arterial occlusive disease in the lower extremities (LEAOD). Some authors have already studied the extension of the disease, by arteriography, in patients with femoropopliteal disease; nevertheless, none of them has so far used the Intraoperative Distal Prebypass Arteriography (IDA) as the goldstandard in patients with disease in the aortoiliac territory. This study is a clinical, prospective trial, developed by the Division of Vascular Surgery at the University of Sao Paulo to analyse the pre-operative arteriography (POA) in its capacity of showing the true extension of the arterial occlusion and the run-off vessels in LEAOD. The Duplex Ultrasound Arterial Mapping (DUAM) was also tested in the same situations. Extension of the arterial occlusion was defined as the length between the point where the contrast agent leaves the main vessel, and the point where the contrast come back to it, in the arterial system, the later called Refilling Point (RP). Run-off was defined as the sum of the distal arteries continuous with the RP. All of the patients included in this study were subjected in a determined time interval to a POA, a DUAM and a IDA. Forty seven lower extremities were studied in 33 patients (34 with aortoiliac, and 13 with femoropopliteal disease). POA detected the true RP in 53% of the instances, with a bad reprodutibility of the gold-standard (k = 0,44, P > 0,001). The DUAM detected the RP 74,5%, with a good results reprodutibliity (k = 0,68, P < 0,001). In the assessment of run-off vessels POA and DUAM have detected, respectively, 125 and 167 of the 183...