1211673128 elliot garita parte i trombosis venosa profunda

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  • TROMBOSIS VENOSA PROFUNDA Dr.Elliott Garita J.Ciruga CardiovascularCosta Rica

  • TVPSinnimo de tromboflebitis profunda o flebotrombosis630.000 casos/ ao/ Estados UnidosMuchos no diagnosticadosAlta asociacin con embolismo pulmonarMortalidad de 200.000 ptes/ao/Estados Unidos - Embolismo pulmonar

  • Epidemiologa de la enfermedad tromboemblica venosa (ETV)90*60*30*California study3183*60*123*Frenchstudy190,000 casos/ao117*220*Total ETV65,000 casos/ao-160*TVP25,000 casos/ao-60*EPIncidencia en Espaa**Minnesota study2European consensus1. Oger E. Thromb Haemost 20002. Heit JA et al. Thromb Haemost 20013. White et al. Thromb Haemost 2005*(casos/100.000 habitantes/ao)** Estimado

  • Mortalidad en ETVSUPERVIVENCIA DESPUES DEL PRIMER EPISODIO DE ETV (%)Heit JA et al. Thromb Haemost 2001

  • La HemostasiaCoagulacinAntifibrinolisisAnticoagulacinFibrinolisis

  • CoagulacinAntifibrinolisisAnticoagulacinFibrinolisisENFERMEDADES HEMORRGICAS

  • CoagulacinAntifibrinolisisAnticoagulacinFibrinolisisENFERMEDADES TROMBTICAS

  • Etiopatogenesis de ETVmecanismos de la formacin del tromboPlaquetasTromboColgenoTRIADA deVIRCHOW(1856)*FT: Factor TisularFT*Estasis Sangunea (En las vlvulas)Trauma(Cambios) en la Pared vascularHiperviscosidadsangunea

  • Formacin del Cogulo

    (Glbulos Rojos rodeados de Fibrina)

  • Lesin parietalTraumatismos mecnicosLesiones qumicasMicrobianasInmunolgicos

  • Estasis VenosaEdadCardiopatasEstados de ShockVaricesHipotona venosaInmovilidadCompresionesAlteraciones respiratorias

  • HipercoagulabilidadGrupo AAnticoncepcin oralEmbarazo-puerperioObesidadNeoplasiasTranstornos hematolgicosSepsisCiruga

  • Factores de riesgo leveCiruga menor en pacientes menores de 40 aos

  • Incidencia de ETV relacionada con la edadHeit JA et al. Thromb Haemost 200101002003004005006007008009001.0000-1420-2430-3440-4450-5460-6470-7480-84Edad (aos)Incidencia AnualTVPEP TVPTotal ETV

  • Factores de riesgo moderadoPermanentesMayor de 60 aosndice de masa corporal mayor de 27Antecedente de TVPLimitacin de movilidad (encamamiento de >4 d)ICCInsuficiencia respiratoriaCancer progresivoSindromes nefroticosEmbarazo

  • Factores de riesgo altoFactores transitoriosEncamamientoDescompensacin cardiacaDescompensacin respiratoriaDeshidratacinSndromes inflamatorios agudosTrombocitopniaFactores de riesgo mayoresDficit motor completo de una de las extremidades inferiores.Compresin extrnseca sintomtica

  • Factores de riesgo congnitos para ETV Deficiencia de Antitrombina Deficiencia de Proteina C Deficiencia de Proteina S Resistencia a la protena C Activada (APCR)Factor V Leiden Protrombina G20210A Disfibrinogenemias Cambios en el sistema fibrinoltico Incremento en factores VIII. IX y/o XI (congnita o adquirida) APCR sin factor V Leiden (congnita o adquirida?)

  • Factores de riesgo para ETV asociados a ciruga o traumaCiruga con duracin mayor a 30 min en pacientes > de 40 aos: Ciruga Abdominal Ciruga Urolgica Ciruga Ginecolgica Cualquier ciruga ortopdica Neurociruga Otros tipos de cirugaOtros factores: Algunas exploraciones vasculares Catteres venosos centrales Trauma mayor o en miembros inferiores Fracturas o condiciones que requieran aparato de yeso o inmovilizacin prolongada Transplante renal

  • Incidencia de TVP en diferentes tipos de cirugaTVP incidencia (%)01020304050607080RodillaFractura de caderaCadera electivaPrstataAbdominalGinecolgicaNeurocirugaR.T.U. de prstataHernia InguinalAdapted from Bergqvist D et al. Br J Surg 1986

  • Impacto de los factores de riesgo en la incidencia de ETV 11 %24 %36 %100 %020406080100LeveModeradoAltoMuy ALTO(%)Factores de riesgo

  • Etiologa y Anatoma Estudio de 10 aos2762 flevografias35% - TVP39% idioptica83% distales35% Post-operatoria53% femo/po10 % tumoral9 % iliacas8 % traumaticaCleveland 2000

  • ClnicaSntomas locales:Payr - compresin de los vasos tibiales posteriores.Homans - Flexin dorsal del piepesadez de la piernaImpotencia funcionalEdema blando progresivoHipertermia localColor plido (flegmacia alba)/Ciantico (cerlea)

  • Sensibilidad y especificidad del examen fsico en el diagnstico de TVP Signo de Homans75 39 6Trombo Palpable98 10 1Dilatacin venosa superficial 80 30 3Diferencia de temperatura90 30 4Eritema90 18 2Edema en la extremidad completa 88 6 1Edema pantorrilla/muslo 58 68 7Hipersensibilidad en pantorrilla52 71 6Dolor en pantorrilla31 79 5Sntomas/signos Se (%) Sp (%) NSe = sensibilidad; Sp = especificidad ; N = estudiosvs. flebografa incluidaWheeler HB & yerson FA. Haemostasis 1995

  • Trombosis Venosa Profunda

  • PatogenesisEstasis venoso + Activacin coagulacinLesin endotelialFibrino formacinAgregacin plaquetaria

    Trombo blanco LeucocitosTromboOclusin venosaMixto Trombo rojoHematesEvolucinLisis (80%)Otras (calcificacin, sepsis)Desprendimiento Embolia Pulmonar

    *Venous thromboembolism (ETV) is a severe y life-threatening condition that is characterized by the formation de a fibrin clot, thrombosis, inside the veins de the deep venous system, with the consequences derived from the evolution de the venous thrombus, that may grow, progress, y break. If a thrombus is broken, some de its fragments may be dislodged y arrive to the lung, causing pulmonary embolism (EP). Deep vein thrombosis (TVP) y EP are currently considered two aspects de the same disease.ETV is a significant condition because de its Alta incidence y the severity de both its immediate y late complications, that may cause death or serious sequelae.According to European consensus, the incidence rate de diagnosed cases de TVP in the general population is 160 cases/100.000 inhabitants/ao, y the EP rate is 60 cases/100.000 inhabitants/ao, which means a total ETV incidence de 220 cases/100.000 inhabitants/ao. Some recent studies have found variable incidence rates. Thus, in the Oger study (2000), conducted in a French region, incidence was 183 cases/100.000 inhabitants/ao; in the Heit et al. study (2001), conducted in a county de the state de Minnesota in the US, a rate de 117 cases/100.000 inhabitants/ao was reported; y an additional study performed in California (White et al.. 2005) found an incidence rate de 90 cases/100.000 inhabitants/ao.Some racial differences appear to exist in the incidence de ETV: a study conducted in California (White et al.. 2005) showed a Altaer incidence in Caucasians y black Americans (> 100 cases/100.000 inhabitants/ao) as compared to Hispanic or Asian people (< 60 cases/100.000 inhabitants/ao).However, no sex differences have been found in the incidence de ETV (Heit et al.. 2001; Kearon C. 2003; White et al.. 2005.) No reliable epidemiologic data are available in Spain, but it may be extrapolated that approximately 65.000 cases de TVP y 25.000 cases de EP should occur every ao, which would result in a total incidence de ETV de 90.000 cases every ao. Such Alta incidence, combined with the morbidity y mortality de the condition, suggests the real significance de the problem.If data from necropsy studies are considered, incidence would be much greater (approximately ten Tiempos greater).

    Heit JA et al The epidemiology de venous thromboembolism in the community. Thromb Haemost 2001;86:452-463.Kearon C. Epidemiology de postoperative venous thromboembolism: lessons from an administrative data base. Thromb Haemos 2003; 90:367-368.White RH et al. Effect de ethnicity y gender on the incidence de venous thromboembolism in a diverse population in California in 1996. Thromb Haemost 2005; 93:298-305.Oger E. Incidence de venous thromboembolism: a community-based study in western France. Thromb Haemost 2000; 83:657-660.

    *As regards complications, mortality due to ETV represents 3.5% de total general mortality y 10% de total hospital mortality, though some autopsy studies suggest that this latter figure may be markedly Altaer.The ICOPER study (International Cooperative Pulmonary Embolism Registry) showed in ETV pacientes mortality rates de 13% during hospital stay y 18% at 3 meses. Similarly, the abovementioned Heit et al. (2001) study showed a decrease survival over Tiempo in pacientes who had experienced a first episode de ETV.

    Goldhaber SZ et al. Acute pulmonary embolism clinical outcomes in the International Cooperative Pulmonary Embolism Registry. Lancet 1999;353:24-27.Heit JA et al The epidemiology de venous thromboembolism in the community. Thromb Haemost 2001;86:452-463.*Three factors, defined many aos ago by Virchow y forming his famous triad, have been traditionally implicated in the pathogenesis de ETV.Such three factors include plasmatic activation de coagulation, blood fBaja sBajaing, y vessel wall damage. This latter factor was thought to have a greater influence on genesis de arterial thrombosis as compared to venous thrombosis; however, we now know that vessel damage y the resultant endothelial damage cause the release de substances significantly involved in coagulation activation y thrombus formation.FBaja sBajaing promotes blood stasis in the valves, where activation de coagulation is enhanced. This activation usually starts due to vessel wall damage, that uncovers collagen, with the resultant adhesion y subsequent activation de platelets y the release de tissue factor (TF), that activates the extrinsic coagulation pathway causing the formation de thrombin first y then fibrin. Fibrin, bound to patelets y erythrocytes, forms