Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG)

Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) are procedures to treat coronary artery disease.
This presentation explains these two cases.

1. PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) & CORONARY ARTERY BYPASS GRAFT SURGERY (CABG) SERVED TO: DR. HAMIDREZA RASTEGAR MOGHADAM HIJAZ Prepared by: Zeinab Bazzi

2. Introduction Definition of angioplasty Definition of PTCA Causes outlines (PTCA): Clinical manifestation of Ptca Ptca procedure Risks & complications Contraindications for Ptca

3. Definition Type of bypass Review of the Coronary arteries Indications for cabg outlines (CABG): Purposes Contraindications Procedure of cabg Risks

4. Percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) are procedures to treat coronary artery disease. PTCA involves inserting a catheter with a tiny balloon into a blocked coronary artery. The balloon is inflated to compress fatty deposits and enlarge the artery. Sometimes a stent is placed to keep the artery open. CABG is used for more severe or multi-vessel disease. A healthy blood vessel is grafted around blockages to bypass them and restore blood flow to the heart. Both procedures help relieve chest pain but CABG has better long-term outcomes for more extensive disease. Introduction

5. Angiplasty is a procedure we use to restore blood flow through your arteries. Certain conditions can cause the blood flow to slow, making it difficult for your body to receive necessary oxygen and nutrients. Angioplasty opens up the blocked artery so blood can flow smoothly What is an angioplasty ??

6. Percutaneous transluminal coronary angioplasty (PTCA) is also known as coronary angioplasty. It is a type of percutaneous coronary intervention (PCI), or minimally invasive procedure, to correct clogged arteries. The procedure opens coronary arteries that have been narrowed or blocked due to the build-up of fatty deposits known as plaque. This restores blood flow to the heart muscle. So PTCA performed to open blocked or narrowed coronary arteries caused by coronary artery disease (CAD) and to restore arterial blood flow to the heart tissue without open heart surgery. What is PTCA??

7. Coronary artery disease (CAD) occurs when fatty deposits called " Plaque" build up Inside the coronary arteries. Factors : ** Smoking. **High amounts of certain fats and cholesterol in the blood. **High blood pressure. **High amounts of sugar in the blood due to insulin resistance or diabetes.... Causes:

8. PTCA is performed to restore coronary artery blood flow when the narrowed artery is in a location that can be reached in this manner. Not all coronary artery disease can be treated with PTCA. Your physician will decide the best treatment of your CAD based on your individual circumstances. There may be other reasons for your physician to recommend a PTA. ⚠️Causes:

9. Angioplasty can reduce symptoms such as chest pain and shortness of breath , and enable you to resume normal activity. The doctor may recommend PTCA if: ▪️ The patient were unable to improve his condition through medication or lifestyle changes. ▪️ The patient experience worsening symptoms, such as increased chest pain (angina) or shortness of breath. Why do you need PTCA?

10. clinical manifestation: Chest pain : Severe and prolonged and may be described as crushing, constricting, or oppressive. Radiation of pain to ulner aspect of left arm, neck, jaw and Interscapular region.

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12. ▪️ First , a local anesthesia numbs the groin area. Then, the doctor puts a needle into the femoral artery, the artery that runs down the leg. ▪️ The doctor inserts a guide wire through the needle, removes the needle, and replaces it with an introducer, an instrument with two ports for inserting flexible devices. ▪️ Then the original guide wire is replaced by a thinner wire. ▪️ The doctor passes a long narrow tube called a diagnostic catheter over the new wire, through the introducer, and into the artery. ▪️ On ce it's in, the doctor guides it to the aorta and removes the guide wire. PTCA Procedure:

13. ▪️ with the catheter at the opening of a coronary artery, the doctor injects dye and takes an X-ray. ✴️If it shows a treatable blockage, the doctor backs the catheter out and replaces it with a guiding catheter, before removing the wire. ▪️ An even thinner wire is inserted and guided across the blockage.

14. ▪️ A balloon catheter is then guided to the blockage site. The balloon is inflated for a few seconds to compress the blockage against the artery wall. Then it's deflated. The doctor may inflate the balloon a few more times, each time filling it a little more to widen the passage.

15. ✴️This may then be repeated at each blocked or narrowed site.

16. ✴️The doctor may also place a stent, a latticed metal scaffold, within the coronary artery to keep it open. ▪️ On ce the compression is done, dye is injected and an X-ray is taken to check for changes in the arteries. ▪️ Then the catheter is removed and the procedure is complete.

17. ⚠️PTCA Procedure monitoring Fluoroscopy (a special type of x-ray that obtains real- time moving images) assists the physician in the location of blockages in the coronary arteries as the contrast dye moves through the arteries.

18. Possible risks associated with PTCA: PTCA risks & complications: 🔸 Bleeding at the catheter insertion site (usually the groin, but the arm may be used in certain circumstances) 🔸Blood clot or damage to the blood vessel at the insertion site 🔸Blood clot within the vessel treated by ptca/stent 🔸Infection at the catheter insertion site 🔸Cardiac dysrhythmias/arrhythmias (abnormal heart rhythms) 🔸Myocardial infarction 🔸Chest pain or discomfort 🔸restenosis (blockage in the blood vessels after PTA procedure) 🔸Rupture of the coronary artery, requiring open-heart surgery

19. ⚠️⚠️⚠️⚠️⚠️⚠️⚠️⚠️⚠️ PTCA risks & complications 🔸The amount of radiation used in fluoroscopy during a PTCA or stent procedure is considered minimal; therefore, the risk for radiation exposure is very low. 🔸Radiation exposure during pregnancy may lead to birth defects. Also if the patient is breast-feeding, he should inform the physician. 🔸There is a risk for allergic reaction to the dye. Patients who are allergic to or sensitive to medications, contrast dye, iodine, or shellfish should notify their physician. Also, patients with kidney failure or other kidney problems should notify their physician. 01 02 03 ⚠️There may be other risks depending upon the specific medical condition of the patient. The patient should discuss any concerns with the physician prior to the procedure.

20. Who should not undergo PTCA? DEPENDING ON THE CONDITION OF THE PATIENT AND OVERALL HEALTH, THE DOCTOR MAY RECOMMEND CORONARY ARTERY BYPASS GRAFTING (CABG) INSTEAD. THE PATIENT MAY NEED CABG IF: 🔸The heart muscle is weak. 🔸 Patients have diabetes and more than one severe blockage in their arteries. 🔸The main artery that supplies blood to the left side of the heart is narrow.

21. ✴️Coronary artery bypass surgery is a medical procedure to improve blood flow to the heart . It may be needed when the arteries supplying blood to the heart, called coronary arteries, are narrowed or blocked. ✴️It's a surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease. Arteries or veins from elsewhere in the patient's body are grafted ( internal thoracic arteries, radial arteries and saphenous) to the coronary arteries to bypass atherosclerotic narrowings and improve the blood supply to the coronary circulation supplying the myocardium (heart muscle). This surgery is usually performed with the heart stopped. What is CABG??

22. ▪️ coronary artery bypass grafting. ▪️ CABG — pronounced "cabbage." ▪️ C oronary artery bypass graft surgery. ▪️ Heart bypass surgery. Other names for this surgery are :

23. They refer to the number of coronary arteries bypassed in the procedure. What does (single, double, triple, quadruple and quintuple) bypass refer to ?

24. ▪️ Double bypass means two coronary arteries are bypassed (e.g. the left anterior descending (LAD) coronary artery and right coronary artery (RCA) ▪️ Tr iple bypass means three arteries are bypassed (e.g. LAD, RCA, left circumflex artery (LCX) ▪️ Quadruple bypass means four vessels are bypassed (e.g. LAD, RCA, LCX, first diagonal artery of the LAD) • Bypass of more than four coronary arteries is uncommon. In other words:

25. Review of the coronary arteries:

26. You may benefit from CABG if you have: (indications for CABG): 🔸Coronary heart disease with angina (chest pain) that has not gone away with medicine, or a history of cardiac arrest related to an irregular heartbeat 🔸 Diabetes 🔸 Heart attack due to coronary artery disease that cannot be treated properly with PCI(PTCA) 🔸 Multiple blocked coronary arteries or large amounts of plaque in the left main coronary artery that would be difficult to treat with PCI 🔸 Serious heart failure that affects your heart’s ability to pump blood

27. so the purposes are: 🔸Restore blood flow to the heart 🔸 Relieves chest pain and ischemia 🔸 Improves the patient's quality of life 🔸 Enable the patient to resume a normal lifestyle 🔸 Lower the risk of a heart attack

28. Contraindications For CABG: 🔸Aneurysms 🔸 Valvular diseases 🔸Congenital diseases 🔸Diseases of blood 🔸CABG is not considered appropriate in asymptomatic patients who are at a low risk of MI or death. Patients who will experience little benefit from coronary revascularization are also excluded. 🔸Although advanced age is not a contraindication, CABG should be carefully considered in the elderly, especially those older than 85 years. These patients are also more likely to experience perioperative complications after CABG.

29. ▪️ a n endotracheal tube is inserted and secured by the anaesthetist and mechanical ventilation is started. General anaesthesia is maintained by a continuous very slow injection of Propofol . Procedure of the surgery:

30. 🔸The chest is opened via a median sternotomy and the heart is examined by the surgeon involves creating a 6 to 8 inch incision in the chest (a thoractomy).

31. ▪️ T he heart is cooled with iced salt water, while a preservative solution is injected into the heart arteries. This process minimizes damage caused by reduced blood flow during surgery and is referred to as "cardioplegia "

32. ▪️ T he most commonly used grafts for the bypass are the internal thoracic arteries, radial arteries and saphenous veins. ▪️ When the wanted vessels are harvested, the patient is given heparin to prevent the blood from clotting.

33. ▪️ Before bypass surgery can take place, a cardiopulmonary bypass must be established. Plastic tubes are placed in the right atrium to channel venous blood out of the body for passage through a plastic sheeting (membrane oxygenator) in the heart lung machine.

34. Do you think that Cardiopulmonary bypass and ECMO are the same?

35. ▪️ ECMO is frequently instituted using only cervical cannulation, which can be performed under local anesthesia; standard cardiopulmonary bypass is usually instituted by transthoracic cannulation under general anesthesia ▪️Cardiopulmonary bypass , which is used for short- term support measured in hours, ECMO is used for longer-term support ranging from 3-10 days The differences between ECMO and cardiopulmonary bypass are as follows:

36. ▪️ T he oxygenated blood is then returned to the body. Once Cardiopulmonary Bypass is established, the surgeon places the aortic cross- clamp across the aorta and instructs the perfusionist to deliver cardioplegia to stop the heart and slow its metabolism. Continuing of Procedure of the surgery:

37. ▪️ One end of each graft is sewn on to the coronary arteries beyond the blockages and the other end is attached to the aorta. ▪️ C hest tubes are placed in the mediastinal and pleural space to drain blood from around the heart and lungs. ▪️ The sternum is wired together and the incisions are sutured closed. ▪️ The patient is moved to the (ICU) to recover.

38. ▪️ Nurses in the ICU focus on recovering the patient by monitoring blood pressure, urine output and respiratory status as the patient is monitored for bleeding through the chest tubes. If there is chest tube clogging, Thus nurses closely monitor the chest tubes and under take methods to prevent clogging so bleeding can be monitored and complications can be prevented. ▪️ After awakening and stabilizing in the ICU (approximately one day), the person is transferred to the cardiac surgery ward until ready to go home (approximately four days).

39. Possible risks of coronary artery bypass graft surgery (CABG) include: Risks & complications : 🔸BLEEDING DURING OR AFTER THE SURGERY 🔸Blood clots that can cause heart attack, stroke, or lung problems 🔸Infection at the incision site 🔸Pneumonia 🔸Breathing problems 🔸Pancreatitis 🔸Kidney(renal) failure 🔸Abnormal heart rhythms 🔸Pleural effusions 🔸Failure of the graft 🔸Heart failure 🔸Death ⚠️There may be other risks depending on the specific medical condition of the patient!

40. References : 🔸 MEDLINEPLUS.GO→ HTTP://EMEDICINE.MEDSCAPE.COM/ARTICLE/1893992- OVERVIEW 🔸 UNIVERSITY OF MICHIGAN (HTTPS://MEDICINE.UMICH.EDU 🔸AHA → HTTP://MY.AMERICANHEART.ORG/PROFESSIONAL/GENERAL/2011- ACCFAHA-GUIDELINE-FOR-CORONARY-ARTERY-BYPASS-GRAFT-SURGERY 🔸GLENEAGLE.COM.SG 🔸 CARDIAC SURGERY ASSOCIATES 🔸HTTPS://STANFORDHEALTHCARE.ORG 🔸 HTTPS://PBCARDIOVASCULAR.COM 🔸 CAMBRIDGE UNIVERSITY PRESS 🔸 HTTPS://HOPKINSMEDICINE.ORG 🔸HTTPS://WWW.NHS.UK 🔸 NATIONAL INSTITUTE OF HEALTH (NIH)(.GOV)