AMPUTACIONES EVITABLES
December 19, 2009
CIRUGÍA VASCULAR EN EL PIE PARA EVITAR AMPUTACIONES
El depósito de colesterol en las arterias, la “arteriosclerosis”, es la principal causa de alteraciones en el riego sanguíneo. Cualquier arteria del cuerpo podría verse afectada, pero esta enfermedad se localiza con mayor frecuencia en el corazón y en las piernas. En el primer caso, se afectan las “coronarias”, que son las que riegan el corazón y permiten que se contraiga sin cesar y con la fuerza necesaria. La gravedad de los problemas que provocan, es evidente y por ello los esfuerzos en su prevención y tratamiento son máximos. Sin embargo, la obstrucción de las arterias de las piernas no reciben tanta atención, y sin embargo son la principal causa de amputaciones en nuestro país.
En el documento “La claudicación intermitente o la enfermedad del escaparate” de esta WEB, se explican los signos para reconocer el problema, al menos en fases avanzadas. Hoy quiero abordar las posibilidades de tratamiento en su fase terminal, cunado la amputación es inminente.
La mejor opción para recuperar el riego sanguíneo en las piernas, es la realización de lo que llamamos “by-pass”, palabra de difícil traducción, aunque podríamos llamarlo “derivación” o “puente”. Se trata de conectar “un tubo”, que puede ser una vena o un tubo sintético, en la arteria principal antes de la obstrucción que produce el problema. El otro extremo se conecta en un segmento sano pasada la lesión, con lo que la sangre vuelve a fluir igual que antes, recuperándose el riego. Así conseguimos que gran número de personas puedan volver a tener una movilidad normal cuando a pesar de la medicación se encontraban limitadas. Pero la arteriosclerosis es una enfermedad progresiva, y muchas veces se van afectando zonas más extensas de las arterias de la pierna, haciendo imposible encontrar una parte “sana” donde conectar el extremo distal del by-pass. En estos casos, la cirugía no tiene posibilidades y la falta de riego produce dolores en aumento y finalmente gangrena, que lleva a la amputación.
Hace 10 años, comenzamos un programa para intentar “salvar esas piernas de la amputación” (descrito ya en inglés como “limb salvage”). El primer paso consiste en identificar “algún” segmento más o menos sano en alguna arteria diferente a las que se utilizan habitualmente para los “by-pass”, como son las que se encuentran en los alrededores del pie. Para ello hay que realizar lo que llamamos “arteriografías selectivas” que consisten en llevar contraste a estas zonas que generalmente no se estudian, ya que la sangre, y por tanto el contraste, tardan mucho y llegan con dificultad a ellas, debido precisamente a las obstrucciones generalizadas. En los casos el los que fue imposible ver algún vaso, utilizamos la técnica de los ultrasonidos, el “Dóppler”, para localizar algún segmento con flujo. A partir de ahí, diseñamos una operación específica para cada paciente.
Lo principal para tener éxito, es disponer de una “vena” del propio paciente, ya que los tubos sintéticos se obstruirían con rapidez. Lo segundo, es encontrar el camino más corto para llevar sangre al pie, ya que la longitud influye en los resultados.
Creemos que es importante que el cirujano tenga experiencia en cirugía de las coronarias, ya que el tamaño de las arterias y de las suturas necesarias son similares a las utilizadas en el corazón, y la técnica para el by-pass debe ser exactamente la misma que utilizamos para las coronarias. Hay que utilizar también las lupas de aumento (habituales en la cirugía de las coronarias y que permiten hasta 4,5 aumentos) que permiten la exactitud necesaria en cada punto, porque cualquier imperfección que limite el paso de sangre podría provocar el fracaso de la cirugía.
Todos los pacientes acudieron con el diagnóstico de “isquemia terminal” y todos estaban pendientes de amputación. Solo en dos casos la piel estaba intacta en el pie, Los demás presentaban diversos grados de gangrena, con o sin infección sobreañadida. A todos se informó de la complejidad de la operación y del porcentaje de éxito previsible.
Cada operación de las que hemos realizado en estos años ha sido absolutamente diferente a las demás. En algunos casos, hemos podido realizarla justo antes de llegar al tobillo. En el resto, hubo que abordar directamente el pie. Conseguimos algún segmento de vena utilizable en la misma pierna del by-pass en todos los pacientes excepto en uno, que venía con todas las venas inutilizadas por múltiples operaciones previas, por lo que utilizamos la vena safena de la otra pierna “la sana”. En varias ocasiones, tuvimos que modificar el plan inicial ante la imposibilidad de “coser” la arteria debido a que el calcio ocupaba casi la totalidad del interior del vaso, pero consiguiendo siempre encontrar cerca algún otro punto para el by-pass.
Una vez reestablecido el flujo de sangre, hubo que “limpiar” ampliamente la zona de gangrena en los pacientes con infección añadida, que fueron más de la mitad de ellos.
RESULTADOS
El porcentaje de “piernas salvadas” fue inferior al 70%. En 2 casos, el by-pass dejó de funcionar antes del alta del paciente y hubo que amputarle en el mismo ingreso. En el resto de “fracasos”, la gangrena estaba tan avanzada, que a pesar de un buen flujo de sangre, la infección siguió avanzando, poniendo en peligro la vida de los pacientes, lo que hizo inevitable la amputación posterior.
Pero lo más importante, e incluso sorprendente para nosotros, es que todos los pacientes que recibieron el alta con el by-pass funcionando y las lesiones de la piel cerradas, han conservado su pierna. Algunos han fallecido en estos años por otros problemas (la mayoría son de edad avanzada), pero TODOS han conservado su by-pass con buen flujo a pesar del avance de la arteriosclerosis. Creemos que la presión de la sangre en arterias muy pequeñas ayuda a mantener siempre abierta alguna salida, condición indispensable para que funcione.
El principio en el que se basa esta cirugía “in extremis” es conocido desde hace tiempo, y es el llamado “By Pass a segmento arterial aislado”. Consiste en llevar flujo a una arteria con sangre (con contraste en el estudio), pero obstruida en ambos extremos. El hecho de tener contraste, significa que la sangre entra y sale de ella a través de vasos pequeñísimos, que aunque no veamos, sabemos que están ahí, y son los que distribuyen la “nueva” sangre que llega por el bypass. Nosotros hemos comprobado que esto también funciona con las pequeñas arterias del pie, y que esto se mantiene a lo largo de los años ayudándonos de “anticoagulantes” (el Sintrom, que retrasa la aparición de trombos) y de “antiagregantes” (que evitan las obstrucciones por plaquetas). Pero la evidencia es que después de 10 años, hemos conseguido salvar un número significativo de piernas que ya estaban de antemano abocadas a la amputación, con unos resultados que se han mantenido durante años más allá incluso de nuestras propias expectativas previas. Por ello, todos los pacientes que van ser amputados deberían reestudiarse, buscando la posibilidad de aplicar esta técnica que podría evitar la pérdida de la pierna.
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Gracias por los comentarios. Pero mejor que escribirlo, es comprobar la satisfacción del que pensaba que tenia la pierna perdida y la ve de nuevo con el riego recuperado. Hoy he dado de alta a otro de estos pacientes, y es muy reconfortante.
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