sábado, 7 de julio de 2007

Nuevas indicaciones para el uso de stents medicados

Nuevas indicaciones para el uso de stents medicados

Drs. Francisco Tortoledo R, Braulio Vargas, Juan Simón Muñoz R.
Laboratorio de Exploraciones e Intervenciones Cardiovasculares. Instituto Médico La Floresta. Caracas, Venezuela.

Avances Cardiol 2006;26(1):10-5

RESUMEN
El uso de stents medicados ha reducido significativamente la reestenosis en lesiones coronarias sencillas, casi al nivel de haberla eliminado. Sin embargo, surge la interrogante de qué resultados se pueden obtener con situaciones más complejas como las lesiones en bifurcaciones, tronco de la coronaria izquierda no protegido y el infarto agudo del miocardio, las cuales representan un desafío para el cardiólogo intervencionista. Este artículo hace una breve revisión de la literatura más reciente en búsqueda de una respuesta. La evidencia disponible es favorable al uso de stents medicados en el tratamiento de lesiones en bifurcaciones, obstrucciones crónicas y reestenosis intra-stent (indicación IIa), sugiriendo precaución y la necesidad de más estudios concluyentes en el caso de lesiones en el tronco de la coronaria izquierda no protegido y el infarto agudo del miocardio (indicación IIb). Se menciona la formación de aneurismas coronarios asociados a su empleo.


SUMMARY
The advent of drug eluting stents has almost abolished reestenosis (efficacy) in large vessels with type A lesions. However, the incidence of sub-acute thrombosis has not decreased and is still present even after one year of implant, with the known consequences of myocardial infarction and/or death (safety). On the other hand, the interventional cardiologist faces in the daily life patients with lesions at bifurcations, in the left main coronary artery, in the setting of an acute ischemic event, with chronic total occlusions, with in-stent restenosis, etc., which are not well represented in the trials so far available. Its application in bifurcations (type IIa indication) must be tailored to the individual patient, with the primary goal of performing “provisional stenting” of the secondary branch and avoid, if possible, an excessive amount of metal at the bifurcation site which has been shown to increase the restenosis rate. The left main coronary artery stenosis (type IIb indication) must be treated surgically, until the long term follow-up of the ongoing trials are available. In the setting of acute myocardial infarction, drug eluting stents should not be used, which is a type IIb indication, due to the high clot burden which increases the rate of SAT, although they are superior in chronic total occlusions (type IIa indication). Finally, in the situation of intra-stent restenosis, the use of drug eluting stents is considered a type IIa indication, although there is still controversy about it and long term follow-up of randomized studies are not yet available. The development of coronary aneurysms associated to the use of DES must be considered. Efficacy should not be confused with safety, and once again, “an ounce of prevention is better than a pound of cure”.

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