Surgical Intervention for Surgical Intervention for Coronary Artery DiseasesCoronary Artery Diseases

ByDr. Hanan Said Ali

Learning ObjectivesLearning ObjectivesDefine coronary revascularization.Identify types of Coronary

revascularization.Describe the following procedures: Percutaneous Transluminal

Coronary Angioplasty and stent. Directional Coronary Atherectomy

(DCA).

Learning ObjectivesLearning Objectives Rotablation (Percutaneous

Transluminal Rotational atherectomy or PTRA).

Cutting Balloon. Transmyocardial Laser

Revascularization (TMLR):. Coronary Artery Bypass

Grafting(CABG.• Explain the nursing management.

Coronary Coronary revascularizationrevascularization

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

Coronary revascularization Coronary revascularization Cont.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.

1- Percutaneous 1- Percutaneous Transluminal Coronary Transluminal Coronary Angioplasty ( PTCA)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.

 

1- Percutaneous Transluminal 1- Percutaneous Transluminal Coronary Angioplasty ( PTCA)Coronary Angioplasty ( PTCA)

Coronary revascularization Coronary revascularization Cont.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.

Percutaneous Percutaneous Transluminal Coronary Transluminal Coronary Angioplasty and Stent 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.

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

Coronary revascularization Coronary revascularization Cont.Cont.

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

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.

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

RotablationRotablationtip spins at high speed to tip spins at high speed to grind plaque awaygrind plaque away

Coronary revascularization Coronary revascularization Cont.Cont.

5. Cutting BalloonThe 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.

5. Cutting Balloon5. Cutting Balloon

6. Transmyocardial Laser 6. Transmyocardial Laser Revascularization (TMLR):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.

Coronary revascularization Coronary revascularization Cont.Cont.

Coronary Artery Bypass Coronary Artery Bypass Grafting(CABG) 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.

Coronary Artery Bypass Coronary Artery Bypass Grafting(CABG) Grafting(CABG)

IndicationsIndicationsChronic anginaUnstable anginaAcute myocardial infarctionAcute failure of percutaneous transluminal coronary angioplasty (PTCA)

Severe coronary artery disease

Coronary Artery Bypass Coronary Artery Bypass Grafting(CABG) Cont.Grafting(CABG) Cont.Most common

arteries bypassed:◦Right coronary artery

◦Left anterior descending coronary artery

◦Circumflex coronary artery

Coronary Artery Bypass Grafting(CABG) Cont.

Conduits Used for BypassSaphenous vein used for bypassing right coronary artery and circumflex coronary artery

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

Coronary Artery Bypass Grafting(CABG) Cont.

Bypass of arteries:◦ Incision in target

artery:

Anastamosis of graft with artery:

Coronary Artery Bypass Grafting(CABG) Cont.

Coronary Artery Bypass Grafting(CABG) Cont.

Nursing ManagementNursing Management

PreoperativeObtain 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.

Nursing ManagementNursing ManagementPostoperativeAssesses 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.

Nursing Management Cont.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.

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.

Thank You