Coronary angioplasty

This slide will provide illustrative information regarding coronary angioplasty . It also focus on practical area knowledge of cardiac catheterization which one should focus while caring patient with coronary angioplasty.

1. Prepared by: Sonali Koiri BNS 3 rd Year Roll no : 19 Therapeutic Intervention: CORONARY ANGIOPLASTY

2. Content s : Introduction Indication Relative contraindication Articles/ Equipment Patient preparation Procedure After care Complication Patient education / Health teaching

3. Introduction Percutaneous Coronary Intervention(PCI) , commonly known as Percutaneous Transluminal Coronary Angioplasty (PTCA) , is a non-surgical procedure used to treat the stenotic coronary arteries found in Coronary Artery Disease (CAD). The term PCI now encompasses the broad array of balloons , stents and adjunctive devices required to perform safe and effective percutaneous revascularization in complex coronary artery lesions.

4. Indication: ST elevation MI Non ST elevation MI Stable angina (refractory to medical management) Unstable angina

5. Relative contraindication: Presence of any significant comorbid condition that severly limit lifespan of patient Multivessel coronary artery disease Active bleeding / hemorrhagic stroke Abnormal serum creatinine level Active endocarditis Severe coagulopathy Critical electrolyte imbalance

6. Vascular access: Femoral artery Brachial artery Radial artery

7. Cardiac Catheterization Lab

8. Equipment Room equipment : C-arm , Monitoring device ,couch , ECG. Procedure equipment: Sheath Wire Catheter Stent Balloon Extension inflator , contrast media, saline flush, nitroglycerine , needle , syringe , guaze , alcohol swap,etc

9. Fluroscopy

10. Radiopaque band

11. Catheters

12. Guide wires

13. Coronary stent

14. Balloon catheter

15. Types of Coronary stent : Bare metal stent (BMS) Drugs eluting stent (DES) { 2.0 mcg Sirolimus } Bioabsorbable Stent (BAS)

16. Protection Lead apron of 5mm lead euivalent is worn during the procedure. Lead glass radiation shielding is used.

17. Patient preparation: Patient may be required to be admitted to hospital the night before the procedure. For some patient overnight stay is not required as it can be done via out patient department services. Medical history of patient including allergies and medication. Nil per oral 6-8 hours before the test. Check vital signs and send blood investigations and report should be collected .

18. Contd Client and his gurdain should be explained about procedure along with its assosiated risks and outcomes. Client should be informed about procedure price and explained about price of stent and its function. Consent form should be signed before procedure. Any questions or doubts should be asked and clarified with doctors before surgery.

19. Contd Patient should be asked to empty bladder and change into a hospital gown. Armpit or groin area shaving is required. IV line is inserted before the procedure.

20. Contd Informing patient about sensation that will be explained during catheterization: Palpitation may be felt when catheter tip touches endocardium . Patient may be asked to cough and breath deeply , especially after injection of contrast agent.

21. Investigation to be done : Complete blood count Random blood sugar Renal function test PT/INR Cardiac enzymes ( Troponin , CK-MB ) Urine RE/ME , ECG Note: Urine pregnancy test in case of child bearing age women.

22. Things to be remember: Before PCI , Chewable Tab Aspirin 300mg and Tab. Clopidogrel 300-600 mg is given. ( Even to the patient on Warfarin therapy) There is no additional need of heparin in patient who undergo PCI while therapeutic on warfarin (INR=2-3) . In patient with severe chest pain, Tab NTG 0.4 mg sublingually in q5mins upto three times.

23. Contd Diabetic medicine Tab. Metformin is held before cardiac catheterization and lactic acidosis . Normoglycemia is no more recommended. Instead , insulin infusion to maintain glucose levels <180mg/dl - >90mg/dl is recommended. If Creatinine level is more than equal to 3 , PCI isn’t recommended. Hydration therapy and dialysis is planned first.

24. Procedure Radial access: 1.Place a needle to the anterior radial artery.

25. 2. Then a guide wire is passed through the needle and guided through arterial system upto heart.

26. 3. A flexible catheter is slipped over the wire and guided upto the heart this is monitored using continous Xray imaging device called Fluroscope and this point a guidewire is removed.

27. 4 .Tip of catheter is positioned to enter coronary artery.

28. 5. A special dye is injected that allow fluroscope to Xray images of arterial interiors and helps in identifying the position of plug. This is called angiogram.

29. 6 . Once the blockage is identified , a flexible guide wire is inserted into artery vessels followed by a balloon tiped catheter over this wire to position itself at the site of blockage.

30. 7.Rapid inflation and deflation of the small balloon pushes the vesseles valve out restablishing the flow of blood in the artery. 8.After the blocked vessels is reopened the deflated balloon catheter is withdrawn from the artery. 9. Some treatment procedure is repeated in case of multiple vesseles blockage. It is known as balloon angioplasty.

31. 10. Once it has been treated a collapsed stent is placed over deflated balloon catheter as it is inserted into the position.

32. 11. When balloon inflated the stent expands and locks itself into cage.

33. 12. Deflated balloon catheter are withdrawn leaving stent behind to hold artery open permanently. 13. Again dye is injected X-ray is taken.

34. After care: After PCI, patient is received to critical care unit.(CCU) Access for consciousness and orientation of patient. Placed patient in supine position , manage all monitoring apparatus , discard soiled linen. Vital sign , oxygen saturation and ECG monitoring should be done. Access for bleeding, hematoma and chest pain.

35. Contd 5 . In radial access, patient is allowed for ambulation within 2 hours but should remain on bed for atleast 3 hours or until effect of sedatives disappeared. 6. In femoral access, 4 to 6 hours bed rest compulsory; Seath is removed after 2-3 hours ( vasovagal reaction may occur so IV atropine should be kept ready for bolus ) ; after applying manual pressure elastic bandage is done along with compression ball.

36. Contd 7. Patient is strictly prohibited to repititive movement of affected arm or leg for 24 to 48 hours. ( one can turn laterally keeping leg straight). 8. Input output monitoring ; Contrast induced nephropathy monitoring should be done. 9. After 2 hours Sips to normal diet is allowed. 10. If no complication arises patient get discharged on next day.

37. Radial Band

38. Complications Myocardial infraction Arrythmias Contrast agent reaction Perforation of heart chambers

39. Contd Misplacement of stent. Infection in the surgical cut. Kidney failure ( higher risk who already had kidney problem) Stroke( Rare)

40. Complication Perioperative mortality : <0.1% Perioperative MI : <3% Stroke : <0.1% Thrombotic Occlusion: 1-3% Restenosis : 10 -30 % in BMS 5-15 % in DES Emergent CABG for unsuccessful procedure : < 1%

41. Health teaching If groin artery was used ,for net 24 hour don’t bend waist or lift heavy object. Don’t submerge puncture site in water. If bleeding occurs lie down and apply pressure for 10 mintues and then contact care provider. Consult primary care provider if fever, swelling ,new bruishing or pain arises. Not to discontinue any medicine without consulting concerned doctor.

42. Contd Lifestyle modification:

43. Any queries?????

44. Summary

45. Thank you

46. Refrences : https://www.ncbi.nlm.nih.gov/books/NBK499894/ https://www.ncbi.nlm.nih.gov/pubmed/11899566 https://reference.medscape.com/drug/glyceryl-trinitrate-po-nitroglycerin-po-342281 Retrived on :3 rd Feb 2020 Dr.Sayami , A. (2015) . Cardiology and Critical Care . National Centre For Health Professional Education . Pg no- 51-52 Hinkle L.J , Cheever H. K, (2014). Brunner and Suddarth’s Textbook of Medical- Surgical Nursing Volume 1 , Wolters Kluwer .