Surgical Intervention for Coronary Artery Diseases

1. Surgical Intervention for Coronary Artery Diseases By Dr. Hanan Said Ali

2. Learning Objectives • Define coronary revascularization. • Identify types of Coronary revascularization. • Describe the following procedures: • Percutaneous Transluminal Coronary Angioplasty and stent. • Directional Coronary Atherectomy (DCA).

3. Learning Objectives • Rotablation (PercutaneousTransluminal Rotational atherectomy or PTRA). • Cutting Balloon. • Transmyocardial Laser Revascularization (TMLR):. • Coronary Artery Bypass Grafting(CABG. • Explain the nursing management.

4. Coronary revascularization • Coronary revascularization procedures are usually undertaken to relieve angina symptoms, although some patients may be referred for prognostic reasons. Candidates for revascularization include those with evidence of continuing extensive ischaemia or symptoms that persist despite optimal medical therapy

5. Coronary revascularization Cont. 1- Percutaneous Transluminal Coronary Angioplasty ( PTCA) • Angioplasty is a method of treating the localized coronary artery narrowing by dilating the blockage using a special double lumen balloon catheter. • It may be used to treat patients with recurrent chest pain that is unresponsive to medical therapy, those with atheromas that occlude at least 70% of the internal lumen of a major coronary artery.

6. 1- Percutaneous Transluminal Coronary Angioplasty ( PTCA) • A balloon angioplasty procedure in which a small balloon at the tip of the catheter is inserted near the blocked or narrowed area of the coronary artery. • 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.

7. 1- Percutaneous Transluminal Coronary Angioplasty ( PTCA)

8. Coronary revascularization Cont. 2- Stent - Coronary stent insertion is an intervention that is used in association with balloon angioplasty to open up a blocked coronary artery. - A stent is a small, metal mesh tube that acts as a scaffold to provide support inside the coronary artery.

9. Percutaneous Transluminal Coronary Angioplasty and Stent • 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. • 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.

10. Coronary revascularization Cont. Percutaneous Transluminal Coronary Angioplasty and Stent

11. Coronary revascularization Cont. 3- Directional Coronary Atherectomy(DCA) Atherectomy is a method of treating the localized coronary artery narrowing by shaving or cutting out the blockage.

12. 4. Rotablation (Percutaneous Transluminal Rotational Atherectomy or PTRA) • 4. Rotablation (Percutaneous Transluminal Rotational Atherectomy or PTRA) • For heavily calcified blockages, the Rotoblation special catheter, with an acorn-shaped, diamond-coated tip, is guided to the point of narrowing in the coronary artery. The tip spins around at a high speed and grinds away the plaque on the arterial walls.

13. 4. Rotablation (Percutaneous Transluminal Rotational Atherectomy or PTRA) Cont. • This process is repeated as needed to treat the blockage and improve blood flow. The microscopic particles are washed safely away in your blood stream and filtered out by your liver and spleen

14. Rotablationtip spins at high speed to grind plaque away

15. Coronary revascularization Cont. 5. 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. • This type of balloon may be used to treat the build up of plaque within a previously placed stent (restenosis)ses the fatty matter into the arterial wall.

16. 5. Cutting Balloon

17. 6. Transmyocardial Laser Revascularization (TMLR): • The C02 TMR therapy is a surgical procedure that relieves chest pain in debilitated heart patients. A cardiac, surgeon utilizes the laser to create approximately 20 to 40 channels to allow oxygen-rich blood to reach prove deprived areas of the Patient's heart.

18. Coronary revascularization Cont.

19. Coronary Artery Bypass Grafting(CABG) • It is still major intervention in the treatment of patients with coronary heart disease. Current CABG is a surgical procedure in which a blood vessel from another part of the body is grafted to the occluded blood vessel so that blood can flow around the occlusion.

20. Coronary Artery Bypass Grafting(CABG) Indications • Chronic angina • Unstable angina • Acute myocardial infarction • Acute failure of percutaneous transluminal coronary angioplasty (PTCA) • Severe coronary artery disease

21. Coronary Artery Bypass Grafting(CABG) Cont. • Most common arteries bypassed: • Right coronary artery • Left anterior descending coronary artery • Circumflex coronary artery

22. Coronary Artery Bypass Grafting(CABG) Cont. Conduits Used for Bypass Saphenous vein used for bypassing right coronary artery and circumflex coronary artery

23. Coronary Artery Bypass Grafting(CABG) Cont. • Internal mammary artery (IMA) used for bypassing left anterior descending coronary artery • Patency rate over 90% after 10 years • If more veins are needed, alternative sites such as upper extremity veins can be used • Patency rate as low as 47% after 4.6 years

24. Coronary Artery Bypass Grafting(CABG) Cont. • Bypass of arteries: • Incision in target artery: Anastamosis of graft with artery:

25. Coronary Artery Bypass Grafting(CABG) Cont.

26. Coronary Artery Bypass Grafting(CABG) Cont.

27. Nursing Management Preoperative • Obtain the client’s medical and surgical history and perform physical examination • Client and family teaching: • e.g Knowledge deficit related to unfamiliarity with diagnostic tests, preoperative preparation, and postoperative care. • Anxiety related to fear of surgery.

28. Nursing Management Postoperative • Assesses the client to provide baseline data. • Compare the ventilator settings with the parameters set by the physician . • Monitor the ECG disturbance in the heart rate and rhythm. • Inspect chest tube and monitor arterial blood pressure.

29. Nursing Management Cont. • Assess the client’s fluid status frequently during immediate postoperative period. • Note the client’s level of consciousness, neurologic status, ability to move. • To prevent infection during changing a client’s dressing , the nurse should observe careful hand washing procedures.

30. Nursing Diagnosis • Risk for impaired gas exchange related to retained secretions, hypoventilation secondary to pain, displacement of chest tubes • Risk for decreased cardiac output related to impaired ventricular contraction. • Risk for infection related to impaired skin integrity.

31. Thank You