managementof patients with cad receiving invasive intervention pci

7/31/2019 Managementof Patients With CAD Receiving Invasive Intervention PCI

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Management of Patients with CADreceiving Invasive Interventions

PCIPrepared by: Ahmad Khalil Al-Sadi (RN, MSN, CNS)


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More than 1 million PCI procedures were performedworldwide in 2000, and more than 62,000 in the UKin 2004.

In 2000, more than 500,000 percutaneous coronaryinterventions (PCIs) were performed in the UnitedStates. By 2004, the number exceeded 650,000 in the

United States with rapid growth in other developedcountries. Worldwide, the number of PCIs continuesto increase annually.

More than 1 million PCI procedures were performedworldwide in 2000, and more than 62,000 in the UKin 2004.


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WHAT IS PCI

Percutaneous Coronary InterventionThe term is used to describe various procedures that

can be used to mechanically improve myocardialperfusion without resorting to surgery.

1) PTCA

2) Stent implantation

3) Atherectomy


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Angioplasty

Angioplasty is the mechanical alteration of a narrowedor totally obstructed vascular lumen, generally causedby atheroma (the lesion of atherosclerosis).

The term derives from the roots "Angio" or vesseland "plasticos" fit for molding.

The term has come to include all manner of vascular

interventions typically performed in a minimallyinvasive or percutaneous method.


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Percutaneous Transluminal

Coronary Angioplasty [PTCA]

A long catheter is passedfrom femoral artery up tothe openings of thecoronary arteries.

Using radioopaque dye andfluoroscopy, areas ofstenosis can be identified.

A deflated balloon ispassed over a guidewire toa site of stenosis, where the

balloon is inflated.


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GOALS OF PTCA

Improve blood flow to myocardium-crackingthe atheroma

Several inflations & balloon sizes may be required to

achieve desired goal, usually defined as less


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PTCA: Outcome

Cannot always successfully perform procedure

Diffuse disease

Total occlusionCalcified disease

Restenosis

Occurs in 25-54% of patientsUsually occurs within 6 months


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Mechanism of angioplasty

The enlargement of the vessel lumen through amechanism ofatheromatous plaque compression.

Most of improvement in luminal diameter followingballoon angioplasty results from stretching of the vesselwalland partial disruption of not only the intimal plaquebut also the media and adventitia, resulting in enlargementof the lumen and the outer diameter of the vessel.

Axial redistribution of plaque material also contributes to

improvements in lumen diameter. Atherectomy devices and, subsequently, intracoronary

stents were developed, in part, to decrease the early andlate loss in luminal diameter observed with conventionalballoon angioplasty.


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Angiographic indications and

contraindications to PTCA

Indications:

Hemodynamically significant lesion in a vessel servingviable myocardium (vessel diameter >1.5 mm)

Pts with lesions >70% stenosis placing large areas of heart

At risk for ischemia.


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Relative contraindications

Left main stenosis or left main equivalent stenosis(Coronary artery bypass graft [CABG] surgery is still thepreferred treatment for left main stenosis. However, this

area is rapidly evolving toward safe and feasible PCIoptions.)

Chronic total occlusion (CTO) with the following:

No proximal stump visible Extensive bridging collaterals present

Diffusely diseased small-caliber artery or vein graft

Other coronary anatomy not amenable to percutaneousintervention


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Once positioned, the balloon is inflated forabout 10 to 30 seconds (occluding coronaryflow). The balloon is then deflated and

withdrawn from the coronary circulation intothe guiding catheter. Injection of contrast intothe coronary artery during cine acquisition

enables assessment of the result.


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S


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Stents

Small stainless steel scaffold supports artery

and enables blood flow. Delivered over balloon catheter.

Half of PTCA procedures now include stenting.


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Metallic stents

Tiny, cylindrical, expandable tubes of metallic mesh, toovercome the restenosis of balloon angioplasty.

Stainless steel or nitinol.

Drug-eluting stents

Metallic stents coated with pure drug or polymer matrixcontaining drug.

Complications:

Thrombosis (antiplatelet agents are required)Restenosis (cell proliferation should be suppressed)


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INTERVENTIONAL CARDIAC

PROCEDURES Intracoronary Stents

Used to prop or support

the arterial wall. Used tokeep vessels open.

Anticoagulant &antiplatelet meds given

to reduce risk forthrombus formation atsite


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an intracoronary stent (a cylindrical steel mesh) is thendeployed. Inflation pressures used for stentdeployment are usually higher (1220 atmospheres).

After about 1530 seconds, the balloon is deflated andwithdrawn into the guiding catheter, leaving the stentmesh pressed firmly against the walls of the coronary

artery. Advances in stent design are such that it is nowoften possible to position a stent across a tightstenosis without pre-dilating the lesion (so-called

primary stent implantation).


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Broad indications for Stent

implantation

Acute or threatened artery closure followingballoon angioplasty, resulted in decreased theneed for emergency surgery.

Elective stent implantation for optimizing theinitial and longer-term revascularization result.


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Comparing Stents with Balloon

Angioplasty

Reduced adverse cardiac events with stents by about 30% in the 6 mos following the procedure.

Decrease risk and need for repeat revascularization of

about 50%. Stents decrease restenosis by providing the largest

intimal angiographic gain and by preventing early recoiland late vessel constriction.

Higher procedural success rate, long term patency, andimproved in-hospital clinical outcome with stentingvein grafts.


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Problems with Stenting

Neointimal hyperplasia Healing process

Cellular proliferation

Thrombosis

Blood clotting

Response to foreign body

Restenosis

Re-narrowing of the vessel


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Drug-eluting stent multiple types of DESs are available, with the 2 most

commonly used in the United States being the sirolimus(Cypher) stent (SES) and the paclitaxel (Taxus) stent (PES).

These stents comprise a metal stent with a polymer that elutesa drug that reduces neointimal hyperplasia. Newer stent

platforms are evolving with more uniform drug deliverysystems and with the ability for some stents to store differentdrugs for local intracoronary delivery.

SES and PES have both been extensively tested in a wide

spectrum of coronary lesions, all of which have demonstratedsignificant reductions in restenosis and target lesionrevascularization (TLR) rates when compared with bare metalstents.


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RAVEL: 1-Year survival free of MI or

repeat revascularization

Controlled release ofcell growth inhibitors from stents hasshown promise in preventing restenosis. Most experience has

accrued with sirolimus. The Randomized Study with the Sirolimus-Coated Bx Velocity

Balloon-Expandable Stent in the Treatment of Patients withde Nova Native Coronary Artery Lesions (RAVEL) evaluateda stent coated with a 5-mm thick layer of a sirolimus-

polymer matrix. The stent releases active drug over a periodof30 days following placement.

1 r d t i 238 p ti t ith t bl / t bl i r il t


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1-year data in 238 patients with stable/unstable angina or silentischemia, a single primary target lesion in a native coronary

vessel of 2.5 to 3.5 mm in diameter, stenosis of 51% to 99%

of luminal diameter, and a TIMI flow rate >1. Study subjectswere randomized to receive the sirolimus-eluting stent or anuncoated stent.

The estimate of survival free from MI and repeat

revascularization. The difference between the two groups wasentirely due to greater need for repeat revascularization inthe uncoated-stent group ( 22.8%) versus the sirolimus-elutingstent group (0%).

None of the sirolimus-eluting stent group had acute, subacute,or late thrombosis, which suggested to the RAVELinvestigators that re-endothelialization had occurred.


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TAXUS I: Results at 6 and 12 months

Encouraging preliminary results on preventing

restenosis have been reported with a paclitaxel-elutingstent in the TAXUS I trial.

To evaluate a stent coated with apaclitaxel-polymermatrix that releases active drug over 10 days, thestudy enrolled 61 patients with lesions of 50% to 99%

luminal diameter in a native coronary vessel of 3.0 mmto 3.5 mm in diameter. Subjects were randomized tothe paclitaxel-eluting stent or an uncoated stent.


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TAXUS I: Results at 6 and 12 months

As shown, at 6 months there was a significantimprovement in the paclitaxel eluting stentcompared with the uncoated stent with regard to

diameter stenosis within the stented area, withno differences at the proximal and distal edges.

At 12 months, the rate of target-lesion PCI was

10% in the control group and 0% in thepaclitaxel-eluting stent group.


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Comparison of Therapy

Hospital Stay:

CABG4-7 days

Angioplasty1-2 daysStent1-2 days

Restenosis:

CABG5-6%, usually after 5 yearsAngioplasty25-45%, usually within 6 months

Stent15-20%, usually within 6 months


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Comparison of Therapy

Cost

CABG $35,000

Angioplasty $17,000

Stent $19,000

Cost-effectivenessAdditive procedures:

Within 5 years, 20-40% of patients have second PTCA, 25%have CABG

Additive costs:

0 years: per patient costs of PTCA 30-50% those of CABG 1 year: 50-60%

3 years: 60-80%

>3 years: >80%


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PCICOMPLICATIONS


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Allergic reactions to contrast dye and

contrast nephropathy

Allergic reactions related to iodine-based contrast agents forangiographic imaging are classified as minor (hives, rash),moderate (urticaria, bronchoconstriction), or severe

(anaphylactoid reaction [as opposed to anaphylactic reaction]with hemodynamic collapse).

In patients with a history of contrast reaction, the risk forrepeated anaphylactoid reaction is generally reported to range

from 17% to 35%. Previous adverse reactions to shellfish or seafood in general

are believed to be associated with future anaphylactoid

reaction to iodine-based contrast.

M di h d fi d


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Most recent studies have defined contrastnephropathyas an increase in serum creatinineconcentration of 25% or an absolute increase of 44mol/L (0.5 mg/dL).

Contrast nephropathy usually first manifests as anelevation in creatinine concentration 24 to 48 hours

after the procedure that peaks 3 to 5 days after theprocedure.

Patient-related factors associated with an increased

risk for contrast nephropathy include diabetes;preexisting renal insufficiency; and, possibly, reducedintravascular volume status.


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In-stent restenosis (ISR)

Pooled data from six trials indicate that the rate of in-stent restenosis steadily increases over the first year,regardless of how restenosis is defined.

At 12 months, 12% of patients require target lesionrevascularization, almost double the rate at 6months.

At 12 months, 15.8% of patients have target vesselfailure.

These findings underscore the importance of at least12-month follow-up when assessing strategies for

reducing in-stent restenosis.


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R i i h b hi h d i l i


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Restenosis is the process by which a treated arterial narrowingrecurs over time.

The restenosis process is now believed to occur because ofnegative arterial remodeling (arterial constriction) and

intimal hyperplasia, combined with other complex processes.

Factors associated with an increased risk for restenosis include

diabetes; unstable or severe angina at the time of PCI; lesionsin the left anterior descending artery or in a saphenous veingraft; total length of the lesion treated; chronically occludedarteries; previously treated lesions; and factors related to

technical aspects of the procedure itself, most notablyminimum luminal diameter immediately afterward.

The restenotic process occurs over the first 1 to 6 to 8 monthsafter PCI.


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The presenting symptom for most patients withrestenosis is exertional angina (25% to 85%); fewer

patients (11% to 41%) present with unstable angina,and presentation with acute MI is rare (1% to 6%).

Stents have been demonstrated to decrease restenosis

rates in saphenous vein bypass grafts, in chronicallyoccluded arteries, and in patients treated with primaryangioplasty for acute MI.

Drug-eluting stents dramatically reduces the rates ofrestenosis compared with bare-metal stents.


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S T


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Stent Thrombosis A catastrophic complication, associated with 30-day mortality

rates in recent series of 20.8% to 26%. Most frequently occurs in the first days to weeks after stent

implantation.

Patients usually present with severe chest pain and often

present with ST-segment elevation.

Patients treated with bare-metal (nondrug-eluting) stentsshould receive 4 weeks of clopidogrel in addition to aspirin to

prevent stent thrombosis. Because of concern that late stent thrombosis may develop in

patients who are treated with drug-eluting stents, most recenttrials have extended clopidogrel treatment to 3 to 6 months

after PCI, in addition to aspirin therapy.

S i f i


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Stent infection Foreign body implantation predisposes to the

development of infections by damaging or invadingepithelial or mucosal barriers, by supporting growth ofmicro-organisms and by impairing host defensemechanisms.

Manifested within the first four weeks after stentimplantation with fever being the clinical hallmark,chest pain, and positive blood cultures.

Stent infection should be suspected and bloodcultures should be withdrawn in all patients presentingwith fever within the first weeks after coronary stentimplantation even in the absence of chest pain, ECG

abnormalities or elevation of cardiac enzymes.

ifi i f h l l i f i b di i i


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verification of the local infection by cardiac imagingmodalities, including transthoracic and transoesophagealechocardiography, coronary angiography, computed

tomography, and magnetic resonance imaging. Compliance with current standards for the prevention of

infections during cardiac catheterisation are measures toprevent infection include the removal of hair from thepuncture site, application of antiseptic to the skin, and the useof sterile drapes. Operators should perform appropriate hand

washing, wear a sterile gown and sterile gloves and a generally

sterile environment should be maintained during theprocedure.

Rapid institution of antibiotic treatment represents themainstay of therapy, and surgical drainage of the infective

focus including stent removal may be necessary.

Ab l l


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Abrupt vessel closureMay occur in as many as 5% of balloon angioplasty

cases and typically develops when compression of thetrue lumen by a large dissection flap occurs, thrombusformation, superimposed coronary vasospasm, or a

combination of these processes. The presence of largecoronary dissections immediately after balloonangioplasty is associated with a 5-fold increase in therisk of abrupt closure.

The use of intracoronary stents and new antiplateletdrugs has decreased the incidence of abrupt closuresignificantly (to


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Factors predictive of abrupt vessel

closure

Preprocedure: Clinical factors: Female gender, Unstable angina, Insulin-

dependent diabetes mellitus, Inadequate antiplatelet therapy.

Angiographic factors: Intracoronary thrombus, >90%

stenosis, Stenosis length 2 or more luminal diameters,Stenosis at branch point, Stenosis on bend ( 45).

Right coronary artery stenosis.

Postprocedure:

Intimal dissection >10 mm

Residual stenosis >50%

Transient in-lab closure

Residual transstenotic gradient 20 mm Hg

M di l I f i


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Myocardial Infarction

can occur during PCI because of coronary dissection, abruptvessel closure, thrombotic occlusion of the epicardial vessel,distal embolization of thrombus or atheromatous material tothe microcirculation, side branch occlusion, coronary spasm,

or a combination of events. The incidence of MI, defined primarily as CK-MB

concentrations elevated to more than two to three times

the upper limit of normal, generally ranges between 5%

and 30%.

Serial CK and CK-MB measurements (6 to 8 and 16 to 24hours after the procedure) should be obtained in patients with

suspected ischemia during PCI.

Emergency Coronary Bypass Surgery and


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Emergency Coronary Bypass Surgery and

Death

Recent data demonstrate that the need for emergencyCABG has decreased since the introduction of coronary

stents and that CABG rates are currently less than 1%.Death is similarly rare, most recent registries andclinical trials report mortality rates of less than 1%.

Factors associated with increased mortality ratesduring PCI include advanced age, female sex, diabetes,

previous MI, multivessel disease, left main orequivalent coronary disease, a large area ofmyocardium at risk, preexisting left ventricularfunction, and preexisting renal insufficiency.

F i d i h i d


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Factors associated with increased

mortality for angioplasty

Clinical Factors:

Female gender, Age >65 years, Unstableangina, Congestive heart failure, Chronic renal failure.

Angiographic Factors:

Left main coronary disease, Three-vessel disease, Leftventricular ejection fraction < 0.30.

Risk index: Myocardial jeopardy score, Proximalright coronary stenosis, Collaterals originate fromdilated vessel.

V l C li i


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Vascular Complications overt bleeding with a decrease in hemoglobin level of at least

30 to 50 g/L (3 to 5 g/dL), need for blood transfusion, orretroperitoneal bleeding.

In current clinical practice, as evidenced by results of recentinterventional trials, rates of major bleeding complications are

low (0.7% to 1.7%).

Insertion of vascular sheaths may produce groin orretroperitoneal hematomas.

Groin hematomas may present with localized pain, lower-extremity edema due to femoral vein compression, orneurologic symptoms due to compression of the femoralnerve, palpation of localized swelling or tenderness in the area,

or loss of sensory or motor function.

Retroperitoneal hematoma should be suspected in


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p ppatients with unexplained hypotension and/or amarked decrease in hematocrit, may experience flank,

abdominal, or back pain. Most retroperitoneal hematomas can be treated

conservatively with discontinuation or reversal of

anticoagulation and antiplatelet therapy and withblood transfusions alone when necessary; only 16% ofpatients require surgery.

Indications for surgical intervention include persistenthypotension, decreasing hematocrit despitetransfusion, or femoral neuropathy (due to nerve

compression).

A femoral pseudoaneurysm is a communication


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p ybetween the femoral artery and the overlyingfibromuscular tissue, resulting in a bloodfilled

cavity. The reported incidence ranges from 0.5% to6.3%.

Groin tenderness, a palpable pulsatile mass, and/or

new bruit in the groin area should promptexamination by Doppler flow imaging.

Can be treated with ultrasound-guided compression,

ultrasound-guided thrombin injection, or surgicalrepair.


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Arterial pseudoaneurysm

An arteriovenous (AV) fistula can result from sheath
http://ajrccm.atsjournals.org/cgi/content/full/166/6/791/FIG3


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( )mediated communication between the femoral arteryand femoral vein, may be suggested by the presence

of a systolic and diastolic bruit and confirmed byDoppler ultrasonography.

Reported incidence ranges from 0.2% to 2.1%.

Can be treated with conservative therapy (careful

observation) in most patients or with ultrasound-guided compression, surgical repair, or percutaneous

implantation of covered stents if necessary.

Characteristics of type A, B, and C


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C a a yp , , a C

lesions

Type A lesions (minimally complex) : Discrete (length


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(length >2 cm) Excessive tortuosity of proximalsegment. Extremely angulated segments

>90 Total occlusions >3 mo old and/or bridgingcollaterals. Inability to protect major sidebranches Degenerated vein grafts with friablelesions

Although the risk of abrupt vessel closure may bemoderately high with Type B lesions, the likelihood

of a major complication may be low in certaininstances such as in the dilation of total occlusions


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OTHER INTERVENTIONAL

CARDIAC PROCEDURES

Although coronary stents are the mainstay for

treatment for obstructive coronary artery disease,

several adjunctive devices and techniques are

available for coronary intervention


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Laser Angioplasty

Uses pulsed laser energy to vaporize plaque & reopenblocked arteries


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Directional coronary atherectomy

Used to debulk coronary plaques. A steel fenestrated cage housing acup-shaped blade is positioned against the coronary lesion by a low-pressure positioning balloon, allowing any protruding plaque to beremoved. Atherectomy is typically followed by balloon dilation andstenting.

Major complication rates associated with directional atherectomy arelow and similar to conventional balloon angioplasty.

Other complications (eg, distal embolization of plaque, transient side-branch occlusion, coronary vasospasm, the no reflow phenomenon,nonQ-wave MI) are greater with DCA than with balloon angioplasty.

Because of the increased complication rates and the greater technicaldemands of DCA compared with balloon angioplasty or stenting, theuse of DCAs has greatly decreased in recent years.

Directional coronary atherectomy has been


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Directional coronary atherectomy has beenshown to improve acute angiographic results

and facilitate both balloon angioplasty andcoronary stenting in select lesions.

It has not been shown to reduce the need forrepeat target lesion revascularization, a clinicalmeasure of restenosis. Its greatest value is foruse in lesions in which the physical removal ofplaque at ostial or bifurcation lesions will allow

successful balloon angioplasty and coronarystenting.

Rotational atherectomycatheter


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y(Rotablator)

Is a device designed for the removal of plaque fromcoronary arteries. This device, which has a diamond-studded burr at its tip, rotates at about 160,000 rpm and isparticularly well suited for ablation of calcific or fibrotic

plaque material . Relies on plaque abrasion and pulverization. Rotational

atherectomy is successful in 92-97% of these cases, with alow incidence of major complications. It causes

dislodgement of particles into the microcirculation, whichoccasionally may lead to infarction and no reflow.Currently, the use of rotational atherectomy is largelyconfined to fibrotic or heavily calcified lesions that can be

wired but not crossed by a balloon catheter.

Used to facilitate stent delivery in complex


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Used to facilitate stent delivery in complexlesions, especially when balloon angioplastyalone has failed.

plays an important role in the treatment ofostial and bifurcation lesions.

The Excimer Laser, Rotational Atherectomy,

and Balloon Angioplasty Comparison(ERBAC) Study showed rotationalatherectomy was associated with a highershort-term success rate than balloonangioplasty (90% vs 80%), but major ischemiccomplications and repeat revascularizationwere higher 6 months after treatment (46% vs

37%).

RHEOLYTIC THROMBECTOMY


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RHEOLYTIC THROMBECTOMY

Rheolytic thrombectomy has become a useful tool for theremoval of coronary thrombi before coronary stenting.

The rheolytic thrombectomy catheter works by forcingsaline out of the distal tip of the catheter at high flow ratesinto a proximal lumen of the catheter. The high saline flow

rates allow for suction of thrombus into the proximal lumenby the Venturi effect .

Although rheolytic thrombectomy has not been shown toreduce restenosis, it is extremely effective in clearing

thrombus and facilitating balloon angioplasty or coronarystenting .

It is of particular value in the treatment of acute myocardialinfarction, sub-acute stent thrombosis, and lesions indegenerated saphenous vein grafts.


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DISTAL PROTECTION DEVICES

Used to prevent embolization of particulate matterduring percutaneous coronary intervention.

It is approved for percutaneous coronaryintervention on saphenous vein grafts, occludes thevein graft with a balloon during intervention andallows for removal of particulate matter from the

graft by means of an aspiration catheter, resulted in53% fewer periprocedural ischemic complicationsthan during vein graft intervention without distalprotection.


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Nursing Care of the Client having


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Nursing Care of the Client having

a Coronary Angiogram/or PTCA

PREPROCEDURE CARE

Informed consent, Check forAllergies

Hold Aspirin, Anti-platelet drugs &

any other anti-coagulants NPO 4- 8 hrs prior

Give all meds-especially cardiacmeds with sips of H20

Baseline Head-Toe Assessment,

including peripheral pulses Pt Instruction: They will be awake

during procedure, takes 1-2hrs. Mayexperience a momentary sensationof warmth [hot flash] & metallictaste when dye injected.

POSTPROCEDURE

CARE

VS Q15x1; q30x1,q2

BR, HOB 20-30O Check pressure drsg.

Over arterial site

Immobilize extremity.

Inc. fluid intake, unless

contraindicated

Assess for CP &

Dysrhythmias


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Discharge Instructions

Medications: new drug and potential side effect. Activity:

bath/shower.

Not lifting anything over 5kg

Not driving themselves home Return to work & resume sexual activity.

Things to watch:

Groin site re-bleed Signs of infection over the site

Chest pain.


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Patient basic needs

Alteration in comfort

Actual/potential alteration in hemodynamicstatus.

Anxiety and lack of knowledge.

managementof patients with cad receiving invasive intervention pci

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