Artículo de Revision

Angioplastia en Bifurcaciones: Generalidades y Resultados Actuales

Dr. Ignacio Batista Rago

Centro Cardiológico Americano Montevideo, Uruguay

Introducción

Las lesiones de bifurcación representan hasta un 15-20% del total de las intervenciones de un centro de cardiología intervencionista de alto volumen y están presentes en aproximadamente un 30% de los pacientes con enfermedad multivaso1.

A pesar del interés en esta compleja técnica, la rápida evolución en el desarrollo tecnológico, el uso de nuevos stents fármacoactivos y dedicados para bifurcación; la angioplastia en estas situaciones sigue siendo una de las más complejas en cardiología intervencionista en términos de un menor éxito del procedimiento, así como una mayor tasa de eventos cardíacos adversos a largo plazo.

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Definición de enfermedad de bifurcación coronaria

 La utilización de un lenguaje común es fundamental para la comprensión y el tratamiento de las bifurcaciones, de esta manera el European Bifurcation Club (EBC), han acordado y propuesto el uso de diferentes definiciones.

Las definiciones actualmente empleadas de bifurcación2-3 se basan en la lesión significativa (>50%) de una rama principal (main branch MB) que afecta o está próxima a una rama lateral (side branch SB). En la mayoría de los casos se toma como un SB significativo para definir bifurcación cuando su diámetro acepta el implante de un stent, siendo una relación stent/SB de 1,1/1. A su vez, una lesión de bifurcación también se puede definir de acuerdo a las consecuencias clínicas de la oclusión de ese SB, sabiendo que su importancia no sólo depende de su diámetro sino también de la masa de miocardio en riesgo. Pudiendo considerar a la longitud del SB como un parámetro de la masa miocárdica en riesgo4.

Por otro lado, la bifurcación "verdadera" suele definirse por un diámetro del SB ≥ 2-2,5 mm, y una bifurcación "no verdadera" por diámetros estrictamente menores5. Es decir, este valor absoluto que no tiene en cuenta el flujo coronario relativo en cada una de las dos ramas, siendo fundamental tener en cuenta este punto. Por ejemplo, para una bifurcación con diámetros del sector proximal del MB de 3,0 mm, de 2,4 mm del sector distal del MB y de 2,0 mm del SB, si tomamos esta bifurcación por sus diámetros los 2,0 mm del SB lo tornarían un vaso de pequeño calibre y, por lo tanto, se podría plantear como insignificante. Sin embargo, este SB contribuye con el 40% del caudal proporcionado por los 3,0 mm del sector proximal del MB. El deterioro o pérdida de este SB puede, por ende,  tener efectos adversos sobre el paciente. Con lo cual, la evaluación de la significancia funcional de un SB para la intervención debe basarse no sólo en el diámetro del SB sino también en los diámetros del vaso madre y del diámetro proximal del MB, ya que éstos dictan la distribución de la fracción de flujo y la masa miocárdica en riesgo.

De forma pragmática, la EBC define a la lesión de bifurcación como el estrechamiento de una arteria coronaria que esté adyacente a, y/o involucre el origen de una rama lateral6. Planteando como un SB significativo a una rama que no se quiere perder en el contexto global de un paciente en particular (síntomas, localización de la isquemia, rama responsable de los síntomas o isquemia, viabilidad, circulación colateral, función ventricular izquierda, etc).

Clasificación de tipos de lesiones de bifurcación

El objetivo de la clasificación es asociar a cada tipo de bifurcación con un pronóstico, una dificultad técnica o un tipo de tratamiento óptimo.

La bifurcación afecta a 3 segmentos, el sector proximal del MB (PM), al sector distal del MB (DM) y al SB. La diferencia entre el SB del DM, es que este último tiene un mayor diámetro y una mayor longitud.

Existen varios tipos de clasificaciones que tienen en cuenta estos 3 segmentos, siendo la clasificación de Medina la más simple y práctica para el uso diario.

Los 3 segmentos de la bifurcación se clasifican en 0 (si la obstrucción es <50%) o 1 (si la obstrucción es >50%). Este valor de 0 o 1 es aplicado a cada uno de los 3 segmentos en el siguiente orden: PM, DM y SB (los valores van separados por comas)7. Figura 1

Figura 1. Clasificación de Medina. Las cifras describen en orden secuencial la presencia (1) o ausencia (0) de lesión >50% en la rama principal proximal a la bifurcación, distal a esta y finalmente en la rama lateral. Rev Esp Cardiol. 2006;59(2):183-4

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Según la EBC, las bifurcaciones tienen 2 ángulos: A (approach) entre el PM y el SB y B (between) entre el DM y el SB. Figura 2

Figura 2. Ángulos de la bifurcación.

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Las regiones de bifurcación coronaria presentan un microambiente hemodinámico complejo, el que posteriormente va a actuar a nivel de la placa de ateroma en su localización, su progresión, en los resultados clínicos y sobre el tratamiento.

A lo largo de las paredes laterales del vaso principal y de las ramas laterales, se observa un estrés endotelial bajo, mientras que en los sectores de bifurcación el estrés endotelial es alto.

Los estudios histopatológicos han demostrado que la distribución de la placa en las regiones de bifurcación está relacionada con los patrones locales de estrés endotelial, por lo que en general la placa de ateroma se localiza en los sectores donde el estrés parietal es más bajo y en los sectores donde el flujo coronario es más rápido y sostenido, la carina, tienden a no tener placa de ateroma10.

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Tratamiento de la bifurcación

La complejidad del tratamiento de las bifurcaciones surge del hecho de que las bifurcaciones varían no sólo en la anatomía (carga de placa, ubicación de la placa, ángulo entre las ramas, diámetro de las ramas, sitio de bifurcación), sino también en los cambios dinámicos durante el procedimiento, como el desplazamiento de placa y la disección coronaria.

Como en otras lesiones coronarias, el tratamiento de bifurcaciones coronarias con stents fármacoactivos han demostrado mejores resultados que los stents convencionales 11, por lo que todas las técnicas descritas para bifurcación emplean stents fármacoactivos.

La existencia de múltiples técnicas ha sido la principal razón por la cual el EBC ha propuesto la clasificación MADS3. La ventaja de una clasificación, de las distintas técnicas de bifurcación, es que pueden ser descritas de manera sencilla y que sus resultados pueden ser comparados.

Esta clasificación se basa en 2 principios: la posición de el/los stent/s (1 a 3) en la bifurcación y el orden de implantación.

Hay cuatro estrategias designadas en MADS: estrategia M (main) comienza con un stent en el segmento proximal del MB, estrategia A (across) el primer stent se implanta en el MB través del SB, estrategia D (double) uno o dos stents se liberan por una o dos guías sin recruzar los struts de los stents, estrategia S (side) el primer stent se implanta en el SB con o sin protrusión en el MB.

Después de la implantación inicial de el/los stent/s, se pueden implantar stents adicionales utilizando diferentes técnicas.

En la clasificación de MADS no se describen las distintas maniobras de protección del SB como guía o balón en el SB, ni tampoco las distintas técnicas de aplastamiento del stent del SB (kissing, balloon crush, double kissing crush, etc).

Además de las estrategias "rectas", se describen las estrategias invertidas. Figura 3.

null

Figura 3., Clasificación MADS. El primer stent puede corresponder a una de 4 técnicas de implante: M (vaso principal proximal), A (vaso principal a través de la bifurcación), D (distal, estrategia de doble stent, simultáneo o no) y S (rama lateral). A: descripción de la técnica B: descripción de la técnica “reversa”.  EuroIntervention 2015;11:V23-V26.

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Hasta la fecha existen varios estudios aleatorizados que incluyeron aproximadamente un total de 3000 pacientes comparando los resultados clínicos y angiográficos de una estrategia simple versus una estrategia compleja en pacientes con lesiones sobre bifurcaciones coronarias 12-21.

La estrategia simple se refiere básicamente a una estrategia de stent provisional, (colocación de un segundo stent en el SB después de haber colocado un stent en el MB solamente en casos de resultados subóptimos o inadecuados del SB), mientras que las estrategias complejas se refieren a una gran variedad de técnicas con dos stents. Existe un consenso general que el stent provisional debería ser la estrategia de elección en la mayoría de bifurcaciones coronarias. De hecho, en la mayoría de los estudios aleatorizados, la estrategia simple ha demostrado resultados similares e incluso superiores a las técnicas complejas, con menores tiempos de fluoroscopía y procedimiento.

Un meta-análisis que tomó los datos de los estudios Nordic I y BBC One22, mostró una diferencia significativa en el punto final combinado (mortalidad por todas las causas, infarto de miocardio y revascularización del vaso diana) a favor de la estrategia de stent provisional. A su vez, mostró la superioridad de la estrategia simple en todos los subgrupos (lesiones de bifurcación “verdaderas”, SB de gran calibre, estenosis severas y largas en el SB, ramas de bifurcación de calibres iguales).

El meta-análisis publicado por Gao et al 5 promueve la utilización del stent provisional como técnica de primera elección, pero añade que las técnicas complejas son seguras y pueden ser una opción válida para el tratamiento de bifurcaciones verdaderas con grandes SB (≥2.75mm), lesiones largas en las SB (>5mm) o bifurcaciones con ángulos >60º. Además, este estudio reportó la ausencia de diferencias significativas en el riesgo de trombosis de stent entre una estrategia simple y compleja. En cualquier caso, es importante recalcar el concepto que todas las estrategias complejas requieren experiencia y conocimiento específico de la técnica y, por tanto, solo deberían ser realizadas por centros/operadores con alto volumen de angioplastias.

Una de las principales preocupaciones del stent provisional es la oclusión de la SB después de la liberación del stent en la MB. La oclusión de la SB se produce principalmente por el desplazamiento de la carina y se asocia en muchos casos a una sobredimensión del stent en la MB. Aparte de la sobredimensión del stent en MB, otros de los factores relacionados con la oclusión de la SB son la post-dilatación a alta presión, los ángulos <30º y la diferencia de diámetros entre MB/SB. La necesidad de predilatar el SB es controvertida.

Otra cuestión controvertida es la necesidad de Kissing balloon (KB) final después de implantar el stent en la MB. Aunque la mayor parte de los estudios no reportan beneficios a corto plazo con el KB final tras el stent provisional, el seguimiento angiográfico a los 8 meses del estudio NORDIC-III demostró una menor incidencia de reestenosis del SB en el grupo de KB final, especialmente en caso de bifurcaciones verdaderas23.

Otro concepto importante en las lesiones de bifurcación es la baja correlación angiográfica y la afectación funcional del SB. Se realizaron estudios con guías de presión (FFR) los cuales demostraron que la angiografía tiende a sobrestimar la severidad de las lesiones, sobre todo las que se encuentran a nivel ostial del SB7.

Técnicas complejas de bifurcación ¿Cuál es la mejor?

La mayoría de los estudios aleatorizados comparan las técnicas de Crush y Culotte. Recientemente, se han publicado los resultados a 3 años del estudio NORDIC-III en qué no se han objetivado diferencias clínicas significativas entre las dos técnicas, aunque se observó una mayor tendencia a la aparición de trombosis definida del stent con el Culotte que con el Crush23.

Chen et al publicaron el estudio aleatorizado DK-CRUSH III, el cual comparó el DK Crush y el Culotte para el tratamiento de lesiones bifurcadas en tronco de coronaria izquierda no protegido y observaron que la técnica de Culotte se asociaba con un aumento significativo de MACE, principalmente debido a un aumento de la necesidad de nueva revascularización (TLR)24.

En todo caso, como cada bifurcación es diferente, los operadores expertos tienden a seleccionar la técnica de dos stents, según las características anatómicas de la lesión de bifurcada.

_

Dr. Ignacio Batista Rago 

Centro Cardiológico Americano

Montevideo, Uruguay

 

Bibliografía

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