TROMBOSE AGUDA DE STENT CAROTÍDEO – UMA ENTIDADE CLÍNICA RARA?
DOI:
https://doi.org/10.48750/acv.173Palavras-chave:
Estenose carotídea, Doença carotídea, Stents, Trombose carotídeaResumo
Introdução: A trombose aguda de stentcarotídeo (ACST), que se define de acordo com o Academic Research Consortium como o evento que ocorre nas primeiras 24 horas após o procedimento, é descrita como uma complicação rara de stenting carotídeo mas tem consequências potencialmente catstróficas. AEuropean Society for Vascular Surgery atualizou as suas guidelinesconcluindo que trombólise e o abciximab poderão ser eficazes, mas não fornece recomendações terapêuticas específicas.
O objetivo desta revisão foi assim sumariar a evidência existente relativa a etiologia e abordagem de ACST.
Métodos: Uma revisão de literatura foi realizada usando a base de dados MEDLINE.
Resultados: Não são reportados dados relativos a taxa de incidência de ACST nos grandes ensaios clínicos randomizados publicados. Em cohorts publicadas, a taxa de incidência varia entre 0,5 a 0,8% na maioria dos estudos, mas pode atingir os 33% em contexto agudo pós-acidente vascular cerebral (AVC).
Considerando a etiologia, podemos subdividir em 2 categorias principais: causas sistémicas e complicações técnicas. No primeiro caso, a não adesão / resistência aos antiagregantes plaquetários foram as causas mais reportadas, enquanto que nas complicações técnicas inclui-se a dissecção da artéria carótida e a protrusão da placa. De salientar também que dual layer stentsforam associados a maior risco de ACST.
Existem três abordagens principais para o ACST: farmacológica, endovascular e cirúrgica. A abordagem farmacológica inclui a hipocoagulação, a trombólise e a trombólise facilitada, apesar de o papel das 2 últimas continuar por esclarecer.
O tratamento endovascular foi a abordagem mais comum para ACST intraprocedimento: trombectomia mecânica com ou sem trombólise facilitada concomitante. As opções cirúrgicas incluíram endarterectomia carotídea com explantação dostent, que foi também o bail-outapós mau resultado com tratamento endovascular, atingindo excelentes taxas de recanalização. Nos casos de ACST assintomáticos, o tratamento conservador com hipocoagulação foi unânime.
Discussão: Como conclusão, o ACST é provavelmente uma entidade clínica subestimada associada a múltiplos fatores de risco. A decisão relativa à melhor abordagem deve depender se o ACST ocorre intraprocedimento ou não, da constatação ou não de deterioração do estado neurológico e na experiência do centro. Estudos adicionais devem ser realizados para melhor definir a abordagem ideal.
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Referências
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