PTCA- Percutaneous transluminal coronary angioplasty
Local anesthesia numbs the groin region first. A doctor then inserts a needle into the femoral artery, the artery that runs down the leg. Doctors insert a guidewire through the needle, remove the needle, and replace it with an introducer, an instrument with two ports for inserting flexible devices. A thinner guidewire replaces the original. A long, narrow tube called a diagnostic catheter is passed over the new wire, through the introducer, and into the artery. Afterward, it is guided to the aorta and the guidewire is removed.
A doctor injects dye into a coronary artery and takes an X-ray with the catheter at the opening.
A thinner wire is inserted and guided across the blockage. A balloon catheter is then inserted. A balloon is inflated for a few seconds to compress the blockage against the artery wall. It is then deflated. To widen the passage, the doctor may inflate the balloon a few more times, each time filling it a little more.
Repeat this process at each blocked or narrowed site.
A stent, a latticed metal scaffold, may also be placed within the coronary artery to keep it open. Following compression, dye is injected and an X-ray is taken to check for changes in the arteries. The catheter is then removed and the procedure is complete.
The objectives are:
- Describe the indications for PTCA.
- Describe the contraindications to PTCA.
- Describe the complications of PTCA.
To enhance the delivery of care for patients undergoing PTCA, it is important to improve care coordination among the interprofessional team.
Physiology and Anatomy:
Right and left coronary arteries supply the heart with blood. The left coronary artery (LCA) splits into the left anterior descending (LAD) and left circumflex artery (LCX) branches. LCA supplies blood to the left ventricle. The right coronary artery (RCA) is divided into the posterior descending artery (PDA) and a posterolateral branch (PL).
The RCA supplies blood to the ventricles, the right atrium, and the sinoatrial node. The myocardium is supplied with oxygen and nutrients by the coronary arteries, and their blockage can cause serious adverse health effects. In coronary artery disease, plaque builds up within the coronary arteries, narrowing and blocking the arteries, reducing blood flow to the myocardium.
PTCA's indications depend on several factors. Those with stable angina symptoms who do not respond to maximal medical therapy will benefit from PCI. It provides relief from persistent angina symptoms despite maximal medical therapy. ST-elevation myocardial infarction (STEMI) resulting in 100% occlusion of the coronary artery is indicated for emergency PTCA.
STEMI patients are taken directly to the cath lab upon presentation to prevent further myocardial muscle damage. Patients with non-ST-elevation myocardial infarction (NSTEMI), or unstable angina (also known as acute coronary syndromes), are usually taken to the cardiac catheter lab within 24 to 48 hours.
Contraindications to PTCA are limited. There is a risk of acute obstruction or spasm of the left main coronary artery during the procedure in patients with left main CAD. The procedure is also not recommended for patients with hemodynamically insignificant (less than 70%) stenosis of the coronary arteries.
Initially, PCI was performed solely with balloon catheters. As a result of subclinical outcomes and vessel re-stenosis, other devices such as atherectomy devices and coronary stents were introduced. The use of atherectomy devices alone resulted in poor outcomes. Due to improved clinical outcomes, coronary stents are the most widely used intracoronary devices in PTCA. Traditional bare-metal stents (BMS) and drug-eluting stents (DES) are two types of stents available. DES has a polymer coating that reduces inflammation and endothelial cell proliferation. The most recent DES used in the United States is sirolimus, everolimus, and zotarolimus. The use of antiplatelet therapy is important during the first 12 months after PTCA, to allow adequate endothelial cell formation over the metallic stent.
PTCA is performed by a team consisting of an interventional cardiologist, a nurse, and a radiology technologist. The team members must have specialized and extensive training in the procedure.
A multidisciplinary team evaluates patients and performs pre-procedure testing to determine their suitability for the procedure. Inquiring about allergies to seafood or contrast agents in the past is vital. Pre-procedure laboratory tests include PT and PTT, serum electrolytes, BUN, and creatinine. Hydration is essential. If possible, anticoagulants should be ceased as part of the medication review. Also, common medications such as NSAIDs or ACEIs can be avoided to prevent worsening renal disease.
Before cardiac catheterization, the diabetes medication metformin is held to prevent worsening renal insufficiency and lactic acidosis. A six to eight-hour fast is recommended before the procedure. In cases involving radial artery access, patients are often given intra-arterial calcium channel blockers, nitroglycerin, and heparin to prevent vasospasm. To obtain informed consent, the health care provider should thoroughly explain the procedure and its risks to the patient.
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