Coronary Angiogram and Percutaneous Coronary Intervention

Coronary Angiogram - is a procedure that uses X-ray imaging to see the heart's blood vessels. Coronary angiograms are part of a general group of procedures known as cardiac catheterization. Heart catheterization procedures can both diagnose and treat heart and blood vessel conditions. A coronary angiogram, which can help diagnose heart conditions, is the most common type of heart catheter procedure. During a coronary angiogram, a type of dye that's visible by X-ray machine is injected into the blood vessels of the heart. The X-ray machine rapidly takes a series of images (angiograms), offering a detailed look at the inside of the blood vessels. Coronary angioplasty, initially used in the treatment of patients with stable angina and discrete lesions in a single coronary artery, currently has multiple indications, including unstable angina, acute myocardial infarction (AMI), and multivessel CAD. With the combination of sophisticated equipment, experienced operators, and modern drug therapy, it has evolved into an effective nonsurgical modality for treating patients with CAD. Percutaneous Coronary Intervention (PCI) - is a treatment for persons experiencing myocardial ischemia (inadequate blood flow to the heart) or myocardial infarction (heart attack). The goal of PCI is to open up a coronary artery (blood vessel that brings blood and oxygen to the heart muscle) and restore blood flow. Primary PCI is an emergency treatment performed to reduce the amount of heart muscle permanently damaged by a heart attack. Primary PCI reduces the mortality (death) rate from heart attack.

PROCEDURE: Percutaneous coronary intervention requires the use of the cardiac catheterization suite with special equipment, x-ray capability, and trained personnel. Usually access to the heart and major blood vessels is obtained through the femoral artery in the groin area. The artery is punctured through the skin with a special needle. Under x-ray guidance, a catheter is threaded through the femoral artery up into the aorta

(large artery from the heart) and then gently advanced into the affected coronary artery. There, a balloon is used to open the coronary artery (balloon angioplasty) and restore blood flow. Sometimes a stent (a mesh-like metal tube that holds open the artery) is placed at that time to maintain good blood flow through the damaged area. Percutaneous coronary interventions (PCI) include percutaneous transluminal coronary angioplasty (PTCA) with or without stenting. Primary indications are treatment of angina pectoris (stable or unstable), myocardial ischemia, and acute MI (particularly in patients with developing or established cardiogenic shock). Clinical Indications and Contraindications to PCI Indications

Acute ST elevation myocardial infarction (STEMI) Non ST elevation acute coronary syndrome Stable angina Anginal equivalent (eg, dyspnea, arrhythmia, dizziness/syncope) Asymptomatic or mildly symptomatic patients with objective evidence of a moderate to large area of viable myocardium or moderate to severe ischemia on noninvasive testing

Contraindications

Significant comorbidities (relative contraindication)

ANATOMY OF THE HEART The heart is the organ that helps supply blood and oxygen to all parts of the body. It is divided by a partition or septum into two halves, and the halves are in turn divided into four chambers. The heart is situated within the chest cavity and surrounded by a fluid filled sac called the pericardium. This amazing muscle produces electrical impulses that cause the heart to contract, pumping blood throughout the body. The heart and the circulatory system together form the cardiovascular system. Heart Anatomy: Cardiac Cycle The Cardiac Cycle is the sequence of events that occurs when the heart beats. Below are the two phases of the cardiac

cycle:

Diastole Phase - the heart ventricles are relaxed and the heart fills with blood. Systole Phase - the ventricles contract and pump blood to the arteries.

Heart Anatomy: Blood Vessels Blood vessels are intricate networks of hollow tubes that transport blood throughout the entire body. The following are some of the blood vessels associated with the heart: Arteries: 1. Aorta - the largest artery in the body of which most major arteries branch off from. 2. Brachiocephalic Artery - carries oxygenated blood from the aorta to the head, neck and arm regions of the body. 3. Carotid Arteries - supply oxygenated blood to the head and neck regions of the body. 4. Common iliac Arteries - carry oxygenated blood from the abdominal aorta to the legs and feet. 5. Coronary Arteries - carry oxygenated and nutrient filled blood to the heart muscle. 6. Pulmonary Artery - carries de-oxygenated blood from the right ventricle to the lungs. 7. Subclavian Arteries - supply oxygenated blood to the arms. Veins: Brachiocephalic Veins - two large veins that join to form the superior vena cava. Common iliac Veins - veins that join to form the inferior vena cava. Pulmonary Veins - transport oxygenated blood from the lungs to the heart. Venae Cavae - transport de-oxygenated blood from various regions of the body to the heart. DEVICES and EQUIPMENTS Fluoroscope /x-ray imaging device Cardiac monitor IV line Guidewire Plastic sheath Coronary catheter Radiopaque dye

The term balloon angioplasty is commonly used to describe percutaneous coronary intervention, which describes the inflation of a balloon within the coronary artery to crush the plaque into the walls of the artery. While balloon angioplasty is still done as a part of nearly all percutaneous coronary interventions, it is rarely the only procedure performed. Other procedures that are done during a percutaneous coronary intervention include:

Implantation of stents Rotational or laser atherectomy Brachytherapy (Use of radioactive source to inhibit restenosis.)

Sometimes a small mesh tube, or "stent", is introduced into the blood vessel or artery to prop it open using percutaneous methods. Angioplasty with stenting is a viable alternative to heart surgery for some forms of non-severe coronary artery disease. It has consistently been shown to reduce symptoms due to coronary artery disease and to reduce cardiac ischemia, but has not been shown in large trials to reduce mortality due to coronary artery disease, except in patients being treated for a heart attack acutely (also called primary angioplasty). In acute cases, there is a small but definite reduction of mortality with this form of treatment compared with medical therapy, which usually consists of the administration of thrombolytic ("clot busting") medication.

BEFORE THE PROCEDURE Assess the clients and familys knowledge and understanding of the procedure. Provide additional information as needed. Explain that the client will be awake during the procedure, which takes 1 to 2 hours to complete. A sensation of warmth (a hot flash) and a metallic taste may occur as the dye is injected. A rapid pulse or a few skipped beats, also are common and expected during the procedure. A good understanding of the procedure and expected sensations reduces anxiety and improves cooperation during the procedure. Provide routine preoperative care as ordered. Although the client remains awake, sedation may be given. Signed consent is required, and pre-procedure fasting may be ordered. Administer ordered cardiac medications with a small sip of water unless contraindicated. Regularly ordered medications are continued to prevent cardiac compromise or dysrhythmias during the procedure. Assess for hypersensitivity to iodine, radiologic contrast media, or seafood. An iodine-based radiologic contrast dye is typically used for an angiogram. Iodine or seafood allergy increases the risk for anaphylaxis and requires an alternative dye or special precautions. Record baseline assessment data, including vital signs, height, and weight. Mark the locations of peripheral pulses; document their equality and amplitude. The data provide a baseline for evaluating changes after the procedure. Instruct to void prior to going to the cardiac catheterization laboratory, to promote comfort. AFTER THE PROCEDURE Assess vital signs, catheterization site for bleeding or hematoma, peripheral pulses, and neurovascular status every 15 minutes for first hour, every 30 minutes for the next hour, then hourly for 4 hours or until discharge. The data provide vital information about the clients status and potential complications such as bleeding, hematoma, or thrombus formation Maintain bed rest as ordered, usually for 6 hours if the femoral artery is used, or 2 to 3 hours if the brachial site is used. The head of the bed may be raised to 30 degrees. Bed rest reduces movement of and pressure in the affected artery, reducing the risk of bleeding or hematoma.

 Keep a pressure dressing, sandbag, or ice pack in place over the arterial access site. Check frequently for bleeding (if the access site is in the groin, check for bleeding under the buttocks). Arteries are high-pressure systems. The risk for significant bleeding after an invasive procedure is high. Instruct to avoid flexing or hyperextending the affected extremity for 12 to 24 hours. Minimizing movement of the affected joint allows the artery to effectively seal and promotes blood flow, reducing the risk of bleeding, hematoma, or thrombus formation. Unless contraindicated, encourage liberal fluid intake. An increased fluid intake promotes excretion of the contrast medium, reducing the risk of toxicity (particularly to the kidneys). Promptly report diminished peripheral pulses, formation of a new hematoma or enlargement of an existing one, severe pain at the insertion site or in the affected extremity, chest pain, or dyspnea. While the risk of complications is low, myocardial infarction or insertion site complications may occur. These necessitate prompt intervention. Provide instructions about dressing changes, follow-up appointments, and potential complications prior to discharge.

Cerebral Angiogram Coiling and Stenting

Endovascular Coiling a technique developed as a safer alternative to surgical clipping, endovascular coiling does not involve open cranial surgery, and is typically performed in less time with quicker recovery. The only evidence of the procedure afterward is a small scar in the leg. During the procedure, a small catheter is advanced from a blood vessel in the patients leg up into the blood vessels in the neck. Once in the neck, the catheter is used to introduce a contrast dye that clearly delineates the aneurysm and arteries around it. A smaller catheter is then advanced into the aneurysm in the brain under the guidance of x-rays. At this point, thin flexible platinum coils, approximately twice the width of a human hair, are deposited into the aneurysm (bottom figure, right). The platinum coils conform to the shape of the aneurysm to form a mesh that mimics the fibrous foundation of a thrombus. Blood cells are caught in the mesh, restricting blood flow into the aneurysm and substantially decreasing the risk of rupture.

Indications Endovascular coiling is used to treat cerebral aneurysms. The main goal is prevention of rupture in unruptured aneurysms, and prevention of rebleeding in ruptured aneurysms. In ruptured aneurysms, coiling is performed quickly after rupture because of the high risk of rebleeding within the first few weeks after initial rupture. The patients most suitable for endovascular coiling are those with aneurysms with a small neck size (preferably <4 mm), luminal diameter <25 mm and those that are distinct from the parent vessel. However, technological advances have made coiling of many other aneurysms possible as well.

Procedure Endovascular coiling is usually performed by an interventional neuroradiologist with the patient under general anaesthesia. The whole procedure is performed under fluoroscopic imaging guidance. A guiding catheter is inserted through the femoral artery and advanced to a site close to the aneurysm after which angiography is performed to localize and assess the aneurysm. After this, a microcatheter is navigated into the aneurysm. The treatment uses detachable coils made of platinum that are inserted into the aneurysm using the microcatheter. A variety of coils are available, including Guglielmi Detachable Coils (GDC) which are platinum, Matrix coils which are coated with a biopolymer, and hydrogel coated coils. A series of progressively smaller coils is inserted into the aneurysm until it is completely filled. In the case of wide-necked aneurysms, a stent may be used.

Stenting a process wherein a tiny tube placed into an artery, blood vessel, or other hollow structure (such as one that carries urine) to hold it open. Indications: Most of the time, stents are used to treat conditions that result when arteries become narrow or blocked. Stents are commonly used to treat the following conditions that result from blocked or damaged blood vessels:

Coronary heart disease (CHD) (angioplasty and stent placement - heart) Peripheral artery disease (angioplasty and stent replacement - peripheral arteries) Renal artery stenosis

Abdominal aortic aneurysm (aortic aneurysm repair - endovascular) Carotid artery disease (carotid artery surgery)

Contraindications: Patients in whom antiplatelet and/or anticoagulation therapy is contraindicated. Lesions that are highly calcified or otherwise could prevent access or appropriate expansion of the stent.

Procedure:
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To detemine whether or not the patient has good blood flow into the heart muscle, the coronary arteries may need to be x-rayed. This process is known as angiography. Dye is injeccted into the blood vessels, which will then show up the white on x-ray film. A guide is carefully inserted into the femoral artery through a small incision in the patients upper thigh. From there, it is fed up through the aorta and into position. A catheter is then inserted along the guide wire and positioned so that the dye flows into the coronary arteries. Once the catheter is properly placed, the dye is injected. As the vessels are illuminated areas of narrowing reveal blockage. After the image is taken, the catheter is withdrawn. If the coronary arteries are blocked, and the physician determines that angioplasty/stenting needs to be done next, then the guide wire will be left in place to guide a treatment catheter to the area. A balloon catheter follows a guide wire into the blocked coronary artery. The guide wire used in the angiography procedure is used to guide a balloon catheter to the site of narrowing in the artery. The balloon is inflated and pushes the plague up against the artery walls. The angioplasty is complete. The inflated balloon expands the stent and pushes the plaque up against the artery walls. The balloon catheter is deflated and the stent remains expanded to hold the artery open. The catheter and guide wire are removed. The stent will remain in the artery to keep the artery open. The plaque can reform around the stent, or undergo restenosis, overtime. Drug eluting stents may help prevent this from occurring.

Anatomy of the Brains blood Pathway

The human brain requires a constant supply of oxygen. A lack of oxygen of just a few minutes results in irreversible damage to the brain. The brain requires a rich blood supply, and the space between the skull and cerebrum contains many blood vessels. These blood vessels can be ruptured during trauma, resulting in bleeding.

Preoperative teaching
Preoperative teaching includes instruction about the preoperative period, the surgery itself, and the postoperative period. Instruction about the preoperative period deals primarily with the arrival time, where the patient should go on the day of surgery, and how to prepare for surgery. For example, patients should be told how long they should be NPO (nothing by mouth). Instruction about the surgery itself includes informing the patient about what will be done during the surgery, and how long the procedure is expected to take. The patient should be told where the incision will be. Knowledge about what to expect during the postoperative period is one of the best ways to improve the patient's outcome. Instruction about expected activities can also increase compliance and help prevent complications. POSTOPERATIVE NURSING CARE The anesthesia care provider and circulating nurse transport the patient to the postanesthesia care unit (PACU), where both provide a detailed hand-off report to the receiving PACU nurse. The circulating nurse ensures that the PACU nurse is aware of any neurological deficits that the patient may have presented with preoperatively. The PACU nurse documents the patients arrival vital signs and performs a neurological assessment. The nurse checks the cranial and femoral dressings for bleeding and checks the patients pedal pulses for evidence of occlusion. The patient remains on bed rest with the affected leg extended for a period of time determined by the surgeon. The PACU nurse remains vigilant and immediately reports any signs and symptoms of a retroperitoneal bleeding (eg, low systolic blood pressure, abdominal pain or discomfort) or evidence of hemorrhage or vasospasm (eg, neurological deterioration). Typically, a patient who has undergone craniotomy for aneurysm spends two nights in an intensive care unit (ICU) and an additional three nights in a medical surgical unit before being discharged home. In contrast, a patient who has undergone an endovascular coiling procedure typically spends one night in ICU and one additional night in a medical-surgical unit. Either treatment course may require

rehabilitation before the patient is discharged home, depending on how the patient recovers or if he or she experiences complications. Nursing Considerations Identifies baseline cardiac and vascular status and reviews diagnostic evaluations (eg, electrocardiogram [ECG], laboratory test results). Uses monitoring equipment to assess cardiac and vascular status (eg, ECG, arterial line, pulmonary artery catheter, Doppler). Assesses peripheral pulses, skin pallor, numbness, and tingling of extremities. Observes for signs and symptoms of hypovolemia in postoperative period related to blood loss. Assesses skin integrity, sensory impairments, and susceptibility for infection. Minimizes length of invasive procedure by planning care and obtaining necessary equipment expeditiously. Monitors sterile field and perioperative team members to ensure that asepsis is maintained. Dresses wound at completion of procedure. Assesses readiness to learn and coping mechanisms. Explains sequence of events and reinforces teaching about cerebral aneurysms, surgical treatment options, and recovery. Provides instruction (for surgical procedure and discharge, including signs and symptoms of postoperative hemorrhage. Evaluates for signs and symptoms of skin and tissue injury.