Revascularização miocárdica em multiarteriais

Abstract

The treatment of patients with multivessel disease aims at relieving the symptoms of ischemia, reducing the rate of cardiac events (infarction, arrhythmias), and preserving or restoring left ventricular function, resulting in a greater long-term survival. Important studies carried out during the 1970s comparing coronary artery bypass graft with the medicamentous therapy 1-3 led us to believe that such objectives were better achieved with surgery, especially when indicated to patients with a lesion in the left main coronary artery, three-vessel disease or ventricular dysfunction.Great advances in clinical (statins, potent antiplatelet agents) and surgical (greater use of arterial grafts, better myocardial protection, procedures without extracorporeal circulation) therapy have occurred, resulting in an undeniable improvement in the prognosis of those patients. In recent years, percutaneous transluminal coronary angioplasty has become the most common form of myocardial revascularization used for the treatment of coronary artery disease. The improvement in the techniques and instruments allowed such less invasive form of revascularization to be offered to patients with multivessel disease with safety and efficacy similar to those of surgical revascularization reported in several studies. Silva et al 4 have reported the results of a randomized study carried out in a single center in our country, assessing the long-term advantages of both strategies of revascularization regarding the clinical evolution of patients with multivessel coronary disease.The first case series, published in the 1990s, compared coronary artery bypass surgery with balloon-catheter coronary angioplasty 5-12 . Those studies showed in a uniform way that the mortality and infarction rates did not statistically differ between the 2 forms of treatment ( fig.1); patients undergoing the percutaneous coronary intervention, however, more often required a new revascularization in the long run, due to the occurrence of restenosis. Although those studies had limitations regarding the selection of patients (inclusion of patients with one-vessel disease, clinical and angiographic differences between the populations), they confirmed the safety of coronary angioplasty and its indication to patients with one-or two-vessel disease and less complex lesions.Initially used for managing complications of angioplasty (acute occlusions, vessel dissections), the implantation of coronary stents has become frequent and has been recommended due to their mechanical properties of preventing elastic recoil and negative remodeling of the vascular wall, which are determinant factors in the process of coronary restenosis after balloon angioplasty. By reducing the occurrence of restenosis and acute complications, stent implantation produced results even closer to those obtained with surgery.A meta-analysis 13 comparing coronary artery bypass graft with percutaneous transluminal coronary angioplasty involving 2,643 patients and comprising the ARTS 14 , ERACI II 15 , and SOS 16 studi...

Avaliação do custo do implante programado de múltiplos stents em mais de uma intervenção percutânea em pacientes com doença coronária multiarterial

“…Conclusões: O escalonamento estabelecido pelo SUS, com-O s objetivos no tratamento de pacientes com doença coronariana multiarterial incluem alívio dos sintomas anginosos, redução na taxa de infarto e morte e preservação ou restauração da função ventricular esquerda. Estudos randomizados comparativos de cirurgia de revascularização miocárdica (CRM) com a terapia medicamentosa, publicados na década de 80, mostraram que esses objetivos foram melhores alcançados com a cirurgia, especialmente quando indicada nos portadores de lesão de tronco da coronária esquerda, acometimento triarterial ou disfunção ventricular [1][2][3] .…”