Capítulo 17

Secuelas a largo plazo de TEP y TVP

María del Carmen Gallo

Síndrome post-trombótico

Los pacientes con trombosis venosa profunda (TVP) tienen riesgo aumentado de desarrollar TVP recidivante y síndrome post trombótico (SPT), que ocurre en el 20%-50% de los pacientes con TVP sintomática dentro de 1-2 años del comienzo de los síntomas. En el 5%-10% de los casos la forma es severa, con presencia de úlceras venosas.

El SPT, complicación de la TVP, se caracteriza por reflujo venoso y obstrucción venosa residual, que puede manifestarse como dolor crónico, edema, sensación de pesadez, parestesias, prurito, presencia de várices y lipodermatoesclerosis (1).

Fisiopatología: ver cuadro 1.

Cuadro 1. Fisiopatología del síndrome postrombótico (2)

¿Cuándo un paciente con TVP tiene posibilidades de desarrollar SPT?

  1. La TVP recurrente ipsilateral aumenta el riesgo hasta en 6 veces.
  2. Existe mayor riesgo si la TVP es extensa, e iliofemoral.
  3. Cuando se suman factores de riesgo individual (cirugía, cáncer, obesidad, edad).

¿Puede prevenirse el SPT?

Si bien algunas medidas como la tromboprofilaxis en pacientes hospitalizados es necesaria para reducir el riesgo, la mitad de los casos de TVP ocurren de manera impredecible (2). El tratamiento anticoagulante debe ser óptimo en intensidad y con una duración lo suficientemente prolongada en el tiempo, según lo amerite la situación.

Las medias elásticas de compresión graduada (MECG) reducen el edema, mejoran la microcirculación y disminuyen la hipertensión venosa. Se pueden utilizar MECG de 30-40 mm Hg hasta la rodilla.

¿Cuándo se sospecha el SPT?

Generalmente aparece cuando los síntomas de la TVP no resuelven de manera completa luego de realizar una adecuada anticoagulación (en intensidad y duración). Los síntomas empeoran con la actividad, mejoran con el reposo y el miembro inferior en alto.

Tratamiento

Deambulación precoz. (Nivel de evidencia: Grado 2C).

MECG que serán colocadas por la mañana al levantarse el paciente y retiradas al acostarse. Deben ser usadas por lo menos durante dos años, desconociéndose el tiempo óptimo (Nivel de evidencia: Grado 2B) (3).

Compresión neumática intermitente para los pacientes inmovilizados (Nivel de evidencia: Grado 2C).

Medicamentos: venotónicos derivados de las semillas del castaño de Indias o rutósidos, defibrotide e hidrosmina, para reducir síntomas. (Nivel de evidencia : Grado 2C).

Las úlceras se tratan mediante medicación local tópica, con equipo multidisciplinario (clínicos, dermatólogos, cirujanos plásticos, cirujanos vasculares). Se puede requerir stent de recanalización vascular si hay obstrucción de vena ilíaca o vena cava inferior, o valvuloplastía en la obstrucción permanente fémoro-poplítea.

¿Cómo evaluar el diagnóstico y gravedad del STP?

Para evaluar diagnóstico y gravedad del SPT se han utilizado varios scores (ver tablas I y II).

Tabla 1. Clínica del sindrome post trombótico (4)
Tabla 2. Score Villalta-Prandoni (5)

De acuerdo con los síntomas y signos, un score de 0 a 4 no presenta SPT; de 5 a 9 el SPT es leve; de 10 a 14 es moderado; de 15 o mayor es severo. A las úlceras se las considera presentes o ausentes. Su simple presencia implica severidad.

Hipertensión pulmonar (HP)

Definición

Es la medición de la presión pulmonar media (PAP) ≥ 25 mmHg registrado por cateterismo cardíaco derecho, en reposo. La HP es una enfermedad compleja que produce discapacidad en quien la padece y, según la gravedad, puede tener elevada mortalidad.

Fisiopatología

La histopatología de la HP muestra diversas alteraciones que comprometen las distintas capas arteriales en forma difusa o focal. Afectan arterias de pequeño calibre que intervienen en la resistencia pulmonar. Las lesiones no son patognomónicas y algunas son comunes a todos los tipos de HP (6).

Si bien la HP puede tener distintas etiologías, la que interesa en esta guía es la HP secundaria a enfermedad tromboembólica crónica (HPTC). Para que esta entidad se desarrolle, la HP debe persistir más allá de los 3 meses.

La prevalencia de la HPTC es del 3,8% de los pacientes que sobreviven a un tromboembolismo de pulmón (TEP). No se ha asociado a alteraciones genéticas(6). El mecanismo fisiológico más frecuente está dado por la obstrucción mecánica debido a un TEP no resuelto. La lesión patológica se corresponde con un trombo no organizado fuertemente adherido a la capa media de las arterias pulmonares que puede ocluír totalmente la luz del vaso o producir distintos grados de estenosis (7).

La no resolución de una masa embólica evoluciona a la fibrosis llevando a la obstrucción mecánica de las arterias pulmonares. Otros mecanismos lo constituyen el TEP recidivante o la trombosis in situ, que se inician o agravan por la disfunción del endotelio, por alteraciones plaquetarias o de la cascada de coagulación.

Se encontró la presencia de anticoagulante lúpico en el 10% de de los pacientes con HPTC, y en el 20% se hallaron anticuerpos antifosfolipídicos. El 39% de los pacientes tuvieron niveles aumentados de FVIII.

Manifestaciones clínicas

Síntomas inespecíficos: disnea de esfuerzo (es el síntoma más frecuente), debilidad, angina, síncope, distensión abdominal aparecen ante la falla del ventrículo derecho (VD). Los síntomas en reposo ocurren en los estadíos avanzados.

Signos: alteraciones en la auscultación cardíaca, hepatomegalia, edema, ascitis, extremidades frías, son características de la enfermedad avanzada.

Electrocardiograma (ECG); sobrecarga de VD, dilatación de aurícula derecha, desviación del eje a la derecha, reducción de los voltajes de cara anterior, presencia de arritmias supraventriculares (signos de mal pronóstico) Grado 1-C.

Radiografía de tórax: prominencia del arco de la arteria pulmonar, adelgazamiento de las ramas arteriales periféricas.

Eco doppler cardíaco: permite estimar las presiones pulmonares, conocer estructura y función de ambos ventrículos, descartar valvulopatías, cortocircuito sistémico-venoso, etc. Grado 1-C

Centellografía ventilación/perfusión (V/Q): debe realizarse cuando se quiere descartar o confirmar HPTC. Es más sensible que la tomografía computada .Un estudio normal o de baja probabilidad excluye la HPTC con una sensibilidad del 90-100% (7). Nivel de Grado I-C.

Tratamiento

Son pacientes que requieren de un equipo multidisciplinario : cardiólogos, clínicos, hemodinamistas, hematólogos, neumonólogos etc.

El tratamiento se basa sobre los tres pilares de la HP:

Vasoconstricción

Remodelamiento de la pared de los vasos

Trombosis.

Los pacientes con HPTC deben recibir anticoagulación de por vida con acenocumarol o warfarina, con un rango de anticoagulación que mantenga una razón internacional normatizada (RIN) entre 2 y 3.

También deben recibir anticoagulación los portadores de HP idiopática (Grado 2-C).

Dada la naturaleza recurrente de la enfermedad tromboembólica aguda y la posibilidad de que la resolución de dicho proceso sea parcial o incompleto, se sugiere repetir un centellograma V/Q antes de suspender la anticoagulación, y si es anormal efectuar un ecocardiograma. Esto contribuye a identificar a un grupo de pacientes con tromboembolismo no resuelto.

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