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. These stenotic segments are due to the build up of cholesterol-laden plaques that form due to
atherosclerosis. PCI is usually performed by an interventional cardiologist.
Procedures
The term balloon angioplasty is commonly used to describe percutaneous coronary intervention, which
describes the inflation of a balloon within the coronary artery to crush the plaque into the walls of the artery.
While balloon angioplasty is still done as a part of nearly all percutaneous coronary interventions, it is rarely
the only procedure performed.
Other procedures that are done during a percutaneous coronary intervention include:
• Implantation of stents
• Rotational or laser atherectomy ( percutaneous revascularization, which implies re-
canalizing blocked vasculature)
• Brachytherapy (Use of radioactive source to inhibit restenosis.)
Sometimes a small mesh tube, or "stent", is introduced into the blood vessel or artery to prop it open using
percutaneous methods. Angioplasty with stenting is a viable alternative to heart surgery for some forms of
non-severe coronary artery disease.[9] It has consistently been shown to reduce symptoms due to coronary
artery disease and to reduce cardiac ischemia, but has not been shown in large trials to reduce mortality due
to coronary artery disease, except in patients being treated for a heart attack acutely (also called primary
angioplasty). In acute cases, there is a small but definite reduction of mortality with this form of treatment
compared with medical therapy, which usually consists of the administration of thrombolytic ("clot
busting") medication.[10][11]
PROCEDURE
Technique
The angioplasty procedure usually consists of most of the following steps and is performed by physicians,
physician assistants, nurse practitioners, nurses, radiological technologists and cardiac invasive specialist; all
whom have extensive and specialized training in these types of procedures.
1. Access into the femoral artery in the leg (or, less commonly, into the radial artery or
brachial artery in the arm) is created by a device called an "introducer needle". This
procedure is often termed percutaneous access.
2. Once access into the artery is gained, a "sheath introducer" is placed in the opening to
keep the artery open and control bleeding.
3. Through this sheath, a long, flexible, soft plastic tube called a "guiding catheter" is
pushed. The tip of the guiding catheter is placed at the mouth of the coronary artery.
The guiding catheter also allows for radiopaque dyes (usually iodine based) to be
injected into the coronary artery, so that the disease state and location can be readily
assessed using real time x-ray visualization.
4. During the x-ray visualization, the cardiologist estimates the size of the coronary artery
and selects the type of balloon catheter and coronary guidewire that will be used
during the case. Heparin (a "blood thinner" or medicine used to prevent the formation
of clots) is given to maintain blood flow.
5. The coronary guidewire, which is an extremely thin wire with a radio-opaque flexible
tip, is inserted through the guiding catheter and into the coronary artery. While
visualizing again by real-time x-ray imaging, the cardiologist guides the wire through
the coronary artery to the site of the stenosis or blockage. The tip of the wire is then
passed across the blockage. The cardiologist controls the movement and direction of
Coronary stenting
Traditional ("bare metal") coronary stents provide a mechanical framework that holds the artery wall open,
preventing stenosis, or narrowing, of coronary arteries. PTCA with stenting has been shown to be superior to
angioplasty alone in patient outcome by keeping arteries patent for a longer period of time.[13]
Newer drug-eluting stents (DES) are traditional stents that are coated with drugs, which, when placed in the
artery, release certain drugs over time. It has been shown that these types of stents help prevent restenosis of
the artery through several different physiological mechanisms, which rely upon the suppression of tissue
growth at the stent site and local modulation of the body's inflammatory and immune responses. Five drugs,
Biolimus A9[14], Zotarolimus, sirolimus, everolimus and paclitaxel, have demonstrated safety and efficacy in
this application in controlled clinical trials by stent device manufacturers.[citation needed] However, in 2006 three
broad European trials seem to indicate that drug-eluting stents may be susceptible to an event known as "late
stent thrombosis", where the blood-clotting inside the stent can occur one or more years post-stent. Late
stent thrombosis occurs in 0.9% of patients, and is extremely dangerous and is fatal in about one-third of
cases when the thrombosis occurs.[15][16] New generation DES products, such as the BioMatrix stent marketed
by Biosensors International since January 2008 in Europe, seek to eliminate this risk by using a
biodegradable coating.
After angioplasty, most of the patients are monitored overnight in the hospital but if there are no
complications, the next day, patients are sent home.
The catheter site is checked for bleeding and swelling and the heart rate and blood pressure are monitored.
Usually, patients receive medication that will relax them to protect the arteries against spasms. Patients are
typically able to walk within two to six hours following the procedure and return to their normal routine by
the following week.[10]
Angioplasty recovery consists in avoiding physical activity for several days after the procedure. Patients are
advised to avoid any type of lifting, babysitting grandchildren or other strenuous physical activity for a
week.[11] Patients will need to avoid physical stress or prolonged sport activities for a maximum of two
weeks after a delicate balloon angioplasty.[12]
Patients with stents are usually prescribed an anticoagulant, clopidogrel which is taken at the same time with
acetylsalicylic acid. These medications are intended to prevent blood clots and they are usually taken for at
least the first months after the procedure is performed. In most cases, patients are administrated this type of
medication for 1 year. Also, patients who are doing dental work are advised to cancel it because there is a
risk of endocarditis, an infection of the heart.
[edit] Risks
Coronary angioplasty is widely practiced and has a number of risks;[17] however, major procedural
complications are uncommon. Coronary angioplasty is usually performed by an interventional cardiologist, a
medical doctor with special training in the treatment of the heart using invasive catheter-based procedures.
[citation needed]
The patient is usually awake during angioplasty, and chest discomfort may be
experienced during the procedure; the reporting of symptoms indicates the procedure
is causing ischemia and the cardiologist may alter or abort part of the procedure.
Bleeding from the insertion point in the groin is common, in part due to the use of
anti-platelet clotting drugs. Some bruising is therefore to be expected, but
occasionally a hematoma may form. This may delay hospital discharge as flow from
the artery into the hematoma may continue (pseudoaneurysm) which requires
surgical repair. Infection at the skin puncture site is rare and dissection (tearing) of
the access blood vessel is uncommon. Allergic reaction to the contrast dye used is
possible, but has been reduced with the newer agents. Tearing of the artery resulting
in total blockage and possible myocardial infarction - this can usually be repaired with
a stentA dislodged clot may cause a stroke in some circumstances (in less than 1% of
patients who undergo angioplasties);Bleeding or bruising where the catheters were
inserted;Kidney problems, especially in people with underlying kidney disease and
diabetes - this is caused by the iodine contrast dye used for the X-ray; intravenous
fluids and medications can be given before and after the procedure to try to reduce
this risk.Arrhythmia (irregular heartbeat);[6]Deterioration of kidney function can occur in
patients with pre-existing kidney disease, but kidney failure requiring dialysis is rare. Vascular
access complications are less common and less serious when the procedure is performed via
the radial artery.[citation needed]
death, stroke, VF (non-sustained VT is common), myocardial infarction (heart attack) and Complications
that may occur after or during an angioplasty are the following:
aortic dissection.
A heart attack during or shortly after the procedure occurs in 0.3% of cases; this may require emergency
coronary artery bypass surgery.[18] As with any procedure involving the heart, complications can sometimes,
though rarely, cause death. Less than 2 percent of people die during angioplasty. Sometimes chest pain can
Cardiac catheterization (also called cardiac cath or coronary angiogram) is an invasive imaging procedure
that allows evaluate our heart function. Cardiac catheterization is used to.
Evaluate or confirm the presence of coronary artery disease, valve disease or disease of
the aorta ,Evaluate heart muscle function ,Determine the need for further treatment (such
as an interventional procedure or coronary artery bypass graft, or CABG,
Valvuloplasty
Valvuloplasty is the widening of a stenotic valve using a balloon catheter. Types include:
Aortic valvuloplasty in repair of a stenotic aortic valve. Mitral valvuloplasty in the correction of an
uncomplicated mitral stenosis
Radio frequency ablation (RFA) is a medical procedure where part of the electrical conduction system of
the heart, tumor or other dysfunctional tissue is ablated using high frequency alternating current to treat a
medical disorderRadiofrequency energy is used to destroy abnormal electrical pathways in heart tissue or
normal parts that are contributing to a cardiac arrhythmia. It is used in recurrent atrial flutter, atrial
fibrillation (AF), supraventricular tachycardia (SVT) and some types of ventricular arrhythmia. The energy
emitting probe (electrode) is at the tip of a catheter which is placed into the heart, usually through a vein.
interventional procedure
An interventional procedure is a non-surgical treatment used to open narrowed coronary arteries to improve
blood flow to the heart. An interventional procedure can be performed during a diagnostic cardiac
catheterization when a blockage is identified, or it may be scheduled after a catheterization has confirmed
the presence of coronary artery disease.
An interventional procedure starts out the same way as a cardiac catheterization. Once the catheter is in
place, one of these interventional procedures is performed to open the artery: balloon angioplasty, stent
placement, rotablation or cutting balloon.
Balloon angioplasty: A procedure in which a small balloon at the tip of the catheter is inserted near the
blocked or narrowed area of the coronary artery. The technical name for balloon angioplasty is percutaneous
transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI). When the balloon
is inflated, the fatty plaque or blockage is compressed against the artery walls and the diameter of the blood
vessel is widened (dilated) to increase blood flow to the heart. This procedure is sometimes complicated by
vessel recoil and restenosis.
Balloon angioplasty with stenting: In most cases, balloon angioplasty is performed in combination with
the stenting procedure. A stent is a small, metal mesh tube that acts as a scaffold to provide support inside
the coronary artery. A balloon catheter, placed over a guide wire, is used to insert the stent into the narrowed
artery. Once in place, the balloon is inflated and the stent expands to the size of the artery and holds it open.
Gift of God jobin (ccu ‼)
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The balloon is deflated and removed, and the stent stays in place permanently. During a period of several
weeks, the artery heals around the stent. In this way, restenosis is somewhat diminished.
Angioplasty with stenting is most commonly recommended for patients who have a blockage in one or two
coronary arteries. If there are blockages in more than two coronary arteries, coronary artery bypass graft
surgery may be recommended.
Drug-eluting stents (DES): Drug-eluting stents contain a medication that is actively released at the stent
implantation site. Drug-eluting stents have a thin surface of medication to reduce the risk of restenosis.
Concern was raised in 2006 regarding the safety of drug-eluting stents due to the risk of blood clots forming
on the stent, causing a heart attack. The Food and Drug Administration (FDA) continues to feel that DES,
when used according to approved indications, are safe and effective. Source: Update to FDA Statement on
Coronary Drug-Eluting Stents (January 4, 2007).
If you receive a drug-eluting stent, your doctor will prescribe certain medications for several months after
your procedure to prevent the risk of clotting in the stent. It is extremely important to keep taking the
medications as prescribed until your doctor tells you otherwise.
If you have concerns about drug-eluting stents, please talk with your physician.
Cutting balloon: The cutting balloon catheter has a balloon tip with small blades. When the balloon is
inflated, the blades are activated. The small blades score the plaque, then, the balloon compresses the fatty
matter into the arterial wall. This type of balloon may be used to treat the build up of plaque within a
previously placed stent (restenosis) or other types of blockages.
Cardiac monitoring pressures and volumes Pressure Normal values SOURCE: Pagana, K.D. and T.J.
Pagana. Mosby's Diagnostic and Laboratory Test Reference. 3rd ed. St. Louis: Mosby, 1997. Aortic artery
pressure (routine blood pressure) 90–140/60–90 mm Hg Central venous pressure 2–14 cm H2 End-diastolic
left ventricular pressure 4–12 mm Hg Pulmonary wedge pressure Left atrial: 6–15 mm Hg Pulmonary artery
pressure 15–28/5–16 mm Hg Systolic left ventricle pressure 90–140 mm Hg Volumes Cardiac index (CI)
2.8–4.2 L/min/m2 for a patient with 1.5m2 of body surface area Cardiac output (CO) 3–6 L/min Ejection
fraction (EF) 0.67±0.07 End-diastolic volume (EDV) 50–90ml/m2 End-systolic volume (ESV) 25 ml/m2
Stroke volume (SV) 45±12 ml/m2
http://emedicine.medscape.com/article/161446-overview#a30