Paso a Paso

Técnicas de Abordaje de una OTC

Dr. Alexandre Schaan de Quadros

LATAM SBHCI CTO Registry Coordinator. Coordinador PPG ICFUC, Instituto de Cardiologia do Rio Grande do Sul. Director Científico SBHCI, Brasil Brasil

La indicación de revascularización de las oclusiones totales crónicas (OTC) se determinará por la presencia de síntomas y la extensión de la isquemia y la viabilidad1. La revascularización de una OTC es considerada benéfica si persisten síntomas refractarios, a pesar del TMO (1, 2).

 

De acuerdo con las directrices, la revascularización también se indica ante la presencia de isquemia > 10% del ventrículo izquierdo, independientemente de los síntomas 2,3. Pacientes con CRM previa, son casi siempre tratados con ATC, dado que también ha aumentado el riesgo con la reoperación. En pacientes sin CRM previa, dos tácticas de revascularización son aceptables, con CRM preferido en paciente multivasos y con mayor complejidad anatómica, ATC en los vasos únicos, multivasos menos complejos (Syntax ≤ 22) y rechazos de la CRM (Figura 1).

 

Cómo tratar la oclusión total crónica

La planificación y la preparación son la clave del éxito de la revascularización. El doble acceso está fuertemente recomendado, ya que permite la doble inyección de contraste y un posible enfoque retrógrado3. Este acceso puede ser femoral-radial, bi femoral o bi radial. Un catéter guía de 8 Fr para OTC permite la utilización de todos los materiales dedicados a ATC de OTC y es preferible en casos complejos sobre catéter guías ≤7 Fr4. En general, el mayor soporte de apoyo es necesario para proporcionar el poder de penetración necesario a la guía, sobre el cap proximal a menudo resistente y proveer soporte adecuado para maniobrar un microcatéter a través del canal retrógrado. Sin embargo, el lugar de acceso y la selección de catéteres guía siempre dependerá de la adecuación del paciente, angiografía, así como de la preferencia del operador5.

 

Evaluación angiográfica por inyección simultánea contralateral

La primera e indiscutible etapa de la ATC de la OTC es la doble inyección que permite una buena visualización del vaso proximal y distal, así como la circulación colateral permitiendo la selección de la técnica inicial más adecuada y durante el procedimiento puede disminuir la formación de hematoma subintimal, asegurarse de la posición de la guía (arquitectura del vaso, lumen verdadero, etc), así como evitar la propagación de las disecciones. Casi siempre utilizando inyecciones desde dos catéteres guía cuando hay heterocolaterales o a través de un segundo microcateter por homocolaterales.

 

La evaluación detallada de las características anatómicas obtenidas a partir de la angiografía diagnóstica invasiva es fundamental. Por lo tanto, no se recomienda la aplicación de la ATC de OTC ‘ad hoc’ (excepto en casos de síndrome coronario agudo causado por un puente de safena degenerado), siempre que sea posible ejecutar la ATC sólo después de la realización de una planificación completa del procedimiento. El tiempo dedicado a estudiar la película diagnóstica y eventualmente la angiotomografía, cuando está disponible, es una inversión para una exitosa ATC de OTC, con probables reducciones de las dosis de radiación y volumen de contraste.

 

Parámetros principales a ser evaluados

  1. la morfología del cap proximal;
  2. la longitud de la oclusión;
  3. el tamaño del vaso y la presencia de bifurcaciones más allá del cap distal;
  4. la adecuación de colaterales para acceso retrógrado6.
 
1- Ubicación y morfología del cap proximal

Se refiere a la capacidad de localizar si hay o no ambigüedad en el punto de entrada de la lesión de la OTC por la angiografía invasiva, tomografía o ultrasonografía intravascular y para entender el curso del vaso en el segmento ocluido. Un cap proximal ambiguo aumenta la complejidad del procedimiento y disminuye la probabilidad de éxito7. Un cap proximal favorable es aquella que es afinada, no roma y no tiene colaterales o grandes ramas laterales que dificultan la introducción de la guía en el segmento de OTC.

 
2- Longitud de la lesión

Las lesiones se dicotomizan en aquellas <20 mm y ≥ 20 mm de longitud8. Como se ha descrito anteriormente, en la mayoría de los casos, esta característica puede ser evaluada con precisión sólo por el uso de doble inyección o angiotomografía. En OTCs en que se intenta realizar el cruce anterógrado, OTCs cortas (<20 mm) deben ser abordadas con escalonamiento de guías, mientras que en las OTC largas (≥ 20 mm) la técnica de disección / reentrada subintimal es la preferida, ya que es alta la probabilidad de que en los intentos de cruces con guías anterógrados resulten en entrada subintimal. Con la amplia utilización de la doble inyección, se hizo evidente que la longitud de la oclusión es a menudo más corta que el estimado por inyecciones únicas.

 
3- Características del vaso más allá del cap distal

Se refiere al tamaño del lumen, calcificación, presencia de ramas laterales significativas, enfermedad vascular en el punto de reconstitución y capacidad de visualizar angiográficamente adecuada ese segmento.

 
4- Adecuación de la circulación colateral para técnicas retrógradas

Las características de la circulación colateral favorables para ATC retrógrada son:

  1. Proveniente de un vaso donante sano (o reparado);
  2. Pueden ser fácilmente accesibles con guías y microcatéteres.
  3. Tiene una tortuosidad mínima.
  4. No son la única fuente de flujo para el segmento de la OTC (lo que no coloca al paciente en riesgo de isquemia intra-procedimiento durante el cruce de la misma).
  5. Entra en el segmento de la OTC más allá del cap distal.
 

Las características de circulación colateral más favorables reducen las barreras a la utilización de técnicas retrógradas como una estrategia inicial o como una estrategia de crossover precoz. La comprensión de la circulación colateral también es de importancia durante los intentos de cruce anterógrado, ya que las técnicas de disección y reentrada y la formación de hematomas subintimales pueden comprometer colaterales ipsilaterales o de puente, llevando a la mala visualización del vaso distal en la zona de reentrada y,   ocasionalmente, isquemia. Los injertos degenerados o hasta recientemente ocluidos, anastomosados al vaso blanco distal a la OTC también pueden ser usados como conductos retrógrados para facilitar la ATC.

 

En los artículos listados a continuación, exploraremos las distintas técnicas de abordaje de una OTC, presentados por prestigiosos colegas intervencionistas latinoamericanos.

En esta edición

Artículo de Revision

Indicaciones actuales de revascularización de OTC

Dr. Mario Araya Hormazábal
Paso a Paso

Técnicas de Abordaje de una OTC

Dr. Alexandre Schaan de Quadros
Paso a Paso

1- Algoritmo Híbrido

Dr. Alexandre Schaan de Quadros
Paso a Paso

2- Abordaje Anterógrado con Escalamiento de Guías

Dr. Carlos Esteban Uribe
Paso a Paso

3- Disección Subintimal Anterógrada con Reentrada

Dr. Ricardo Santiago Trinidad
Paso a Paso

5- Abordaje Retrógrado

Dr. João Eduardo Tinoco de Paula
Paso a Paso

6- Manejo de complicaciones en el abordaje de OTC

Dr. José De la Torre A
Entrevista con los Expertos

Situación de la revascularización de OTC en Latinoamérica

Dr. Lucio Padilla
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