Résumé
Resumo Contexto A abordagem cirúrgica para estenose carotídea sintomática está consolidada na literatura para a prevenção de eventos neurológicos, devendo seguir padrões ótimos de qualidade. Entretanto, há uma crescente preocupação relacionada à possibilidade ou não de replicar os dados dos trabalhos controlados no mundo real. Objetivos Avaliar a população com estenose carotídea sintomática submetida a cirurgia e seus desfechos de curto prazo em um contexto de mundo real em um centro de formação profissional. Métodos Tratou-se de um estudo observacional realizado por meio de coleta de dados em prontuário de janeiro de 2012 a janeiro de 2023. Foram excluídos pacientes operados por outras etiologias e com cirurgia cardíaca concomitante. Resultados Foram incluídos 70 pacientes submetidos a angioplastia ou endarterectomia carotídea. Os subgrupos populacionais submetidos a angioplastia ou endarterectomia foram semelhantes. Houve diferença estatisticamente relevante quanto à modalidade anestésica e ao tempo cirúrgico maior para o subgrupo de endarterectomia carotídea. Houve quatro casos de acidente vascular encefálico isquêmico, e três deles estavam relacionados à lesão, sendo dois menores e um maior. Dessa forma, a taxa de acidente vascular encefálico maior relacionado à lesão foi de 1,43% e de qualquer acidente vascular encefálico relacionado à lesão, de 4,29%. A taxa total de eventos adversos cardiovasculares maiores foi de 5,71%. Houve um caso de infarto agudo do miocárdio no grupo angioplastia e nenhum óbito. Não houve diferença estatística entre os grupos de endarterectomia e angioplastia quanto aos desfechos principais. Conclusões Os desfechos acidente vascular encefálico isquêmico, infarto agudo do miocárdio, óbito e eventos adversos cardiovasculares maiores neste centro são semelhantes aos encontrados em estudos clínicos randomizados, demonstrando viabilidade da manutenção deste tratamento em centros com programas de ensino.
Abstract Background Surgical treatment of symptomatic extracranial carotid stenosis is well established for preventing neurological events and should adhere to optimal quality standards. However, there is growing concern as to whether results of controlled trials are replicable in real-world settings. Objectives To assess a symptomatic carotid stenosis population that underwent surgery and its short-term outcomes in a real-world context at a professional training center. Methods Observational study using data collected from medical records from January 2012 to January 2023. Patients undergoing operations for other carotid diseases and with concomitant heart surgery were excluded. Results A total of 70 patients undergoing angioplasty or carotid endarterectomy were included. Population subsets undergoing angioplasty or endarterectomy were similar. Differences in anesthetic modality and a longer operative time in the carotid endarterectomy subgroup were statistically significant. There were 4 cases of stroke, only 3 of which (2 minor and 1 major) were related to the index lesion. Thus, the rate of major operation-related stroke was 1.43% and the rate of any lesion-related stroke was 4.29%. There was 1 case of AMI in the angioplasty group and there were no deaths in the sample. The overall rate of major adverse cardiovascular events was 5.71%. There were no statistical differences between the endarterectomy and angioplasty groups regarding the main outcomes. Conclusions The rates of outcomes of ischemic stroke, acute myocardial infarction, death, and major adverse cardiovascular events at this center are in line with the rates reported by randomized controlled trials, demonstrating the feasibility of carotid surgery in centers with teaching programs.
Résumé
Objective: To describe gender differences in adult patients undergoing carotid angioplasty and its relation to morbidity and mortality at 30 days and 6 months. Material and methods: An observational study from the WHO database comprehending all patients underwent carotid angioplasty in the Department of Hemodynamics Coronary and Peripheral Artery Intervention, Cardiology Hospital 34, IMSS, Monterrey, was conducted in order to ASSESS the differences between genders and their relationship to primary end points within 30 days after the intervention, which were defined as the presence of death related to the procedure, major cerebrovascular event, or myocardial infarction. Results: 279/341 patients/lesions were included for analysis. Within baseline characteristics, women had significantly higher prevalence of type 2 diabetes mellitus (61.4 versus 45.4%, p = 0.006), prior renal angioplasty (21.9 versus 11.5%, p = 0.015), right carotid condition (65.8 versus 53.7%, p = 0.03), prior stroke (20.2 versus 34.4%, p = 0.007) and higher EuroSCORE (3.13 ± 1.72 versus 2.4 ± 1.26, p < 0.001). The masculine gender was only associated with smoking (69.2 versus 35.1%, p < 0.001). In univariate analysis, the female gender was associated with major fatal and non-fatal stroke (4.4 versus 0.9%, p = 0.031). According to symptomatology and subgroups, we found a significant association between women with asymptomatic Increased risk of major cardiovascular events when compared to asymptomatic diseases (9.5 versus 1.4%, p = 0.004). Conclusions: In our center, women who underwent carotid angioplasty present more comorbidities and higher risk in comparison with the male gender. However, these differences do not impact on most adverse cardiovascular events (MACVE) at 30 days. In the subgroup of asymptomatic patients, the risk of major cardiovascular events is significantly higher in the female gender.
Objetivo: Describir las diferencias de género en pacientes adultos sometidos a angioplastia carotídea y su relación con la morbimortalidad a 30 días y seis meses. Material y métodos: Estudio observacional de la base de datos que comprende los casos sometidos a angioplastia carotídea en el Departamento de Hemodinámica e Intervención Coronaria Periférica del Hospital de Cardiología No. 34, IMSS, Monterrey. Se analizaron las diferencias entre géneros y su relación con los puntos finales primarios dentro de los 30 días posteriores a la intervención, los cuales fueron definidos como la presencia de muerte relacionada con procedimiento, evento vascular cerebral o infarto agudo de miocardio. Resultados: Se incluyeron 279/341 pacientes/lesiones. Dentro de las características basales se encontró que las mujeres presentaban una mayor prevalencia de diabetes mellitus tipo 2 (61.4 versus 45.4%, p = 0.006), angioplastia renal previa (21.9 versus 11.5%, p = 0.015), afección de carótida derecha (65.8 versus 53.7%, p = 0.03), evento vascular cerebral (EVC) previo (34.4 versus 20.2%, p = 0.007) y EuroSCORE más alto (3.13 ± 1.72 versus 2.4 ± 1.26, p < 0.001). El género masculino sólo se asoció con mayor tabaquismo (69.2 versus 35.1%, p < 0.001). En el análisis univariado, el género femenino se asoció significativamente con EVC (fatal y no fatal) (4.4 versus 0.9%, p = 0.031). Al dividir en subgrupos de acuerdo con la sintomatología, se encontró una fuerte asociación entre las mujeres asintomáticas con más elevado riesgo de eventos cardiovasculares mayores en comparación con el grupo masculino asintomático (9.5 versus 1.4%, p = 0.004). Conclusiones: En nuestro centro, las mujeres sometidas a angioplastia carotídea presentan más comorbilidades y se encuentran en un riesgo mayor en comparación con el género masculino. Sin embargo, estas diferencias no impactan en la incidencia de eventos adversos cardiovasculares mayores (EACVM) a 30 días. En el subgrupo de pacientes asintomáticos el riesgo de eventos cardiovasculares mayores es significativamente más alto en el género femenino.
Résumé
Introducción La angioplastia transluminal percutánea (ATP) carotídea con implante de stent es un procedimiento eficaz en la prevención del accidente cerebrovascular (ACV) de tipo isquémico, pero su morbimortalidad periprocedimiento aún es discutida. Objetivo Comunicar los resultados de una serie prospectiva de pacientes tratados con ATP. Material y métodos Estudio descriptivo, observacional y prospectivo de la base de datos de tres centros de Hemodinamia de la Ciudad de Buenos Aires, en el que se incluyeron todos los pacientes sometidos a ATP carotídea desde enero de 1998 a noviembre de 2010. Se analizaron los resultados de las ATP realizadas por un mismo operador. Resultados La edad media fue de 69 años, el 58% de los pacientes eran hombres, el 58,8% tabaquistas, el 52% dislipidémicos, el 79,1% hipertensos y el 28% diabéticos. El 19,4% y el 11,6% tenían historia previa de infarto y cirugía coronaria, respectivamente. Desde 1998 hasta 2004 (etapa inicial, n = 54) hubo un 72% de pacientes sintomáticos con indicación de revascularización; en esta etapa no se utilizó sistema de protección cerebral. En la etapa más contemporánea (2004-2010, n = 171), sólo el 17,5% fueron sintomáticos y el uso de sistema de protección cerebral fue sistemático. Se observó una tasa similar de éxito angiográfico en las dos etapas (inicial 96% vs. contemporánea 97%), en tanto que la tasa de éxito clínico de la etapa contemporánea fue superior a la obtenida en la etapa inicial (96,1% vs. 87%; p = 0,016). No se observaron complicaciones cardiológicas. La tasa de muerte o ACV intrahospitalario fue del 4%, del 4,3% (3/70) en los sintomáticos y del 3,2% (5/155) en los asintomáticos; esta tasa fue mayor en la etapa inicial que en la contemporánea 11,1% (6/54) vs. 1,7% (2/171); p = 0,0028. Conclusión La ATP representa una alternativa terapéutica de aceptable seguridad, siempre que sea realizada por operadores experimentados.
Learning curve during percutaneous treatment of carotid lesions Background Percutaneous transluminal carotid angioplasty (PTCA) with stent implantation is an effective procedure for the prevention of ischemic stroke (IS) but its periprocedural morbimortality is still subject to debate. Objective The aim of this study is to report the results of a prospective series of patients treated with PTCA. Methods This is a descriptive, observational, prospective study using the database of three Hemodynamic centers in Buenos Aires, which included all patients submitted to PTCA from January 1998 to December 2010. The results of PTCA performed by the same operator were analyzed. Results Mean age was 69 years, 58% of the patients were men, 58.8% were smokers, 52% had dyslipidemia, 79.1% were hypertensive, and 28% had diabetes. Prior history of acute myocardial infarction and coronary surgery was present in 19.4 and 11.6% of the patients, respectively. From 1998 to 2004 (initial stage, n=54) 72% of symptomatic patients had indication of revascularization, which was performed without cerebral protection in all cases. During the most recent stage (2004-2010, n=171), only 17.5% of the patients were symptomatic and revascularization was performed systematically with cerebral protection. Similar angiographic success was obtained in both stages (initial 96% vs. recent 97%), whereas clinical success rate was greater in the recent phase (96.1% vs. 87%, p=0.016). There were no cardiac complications. The death rate or intrahospital stroke was 4%, 4.3% (3/70) in symptomatic and 3.2% (5/155) in asymptomatic patients; moreover, this rate was higher in the initial than in the recent phase (11.1% 6/54 vs. 1.7% 2/171, p=0.0028). Conclusions PTCA represents an acceptably safe therapeutic alternative to surgical revascularization, providing the procedure is performed by experienced operators.