Surgical Intervention for

Coronary Artery Diseases

By
Dr. Hanan Said Ali
Learning Objectives
Define coronary revascularization.
Identify types of Coronary
revascularization.
Describe the following procedures:
Percutaneous Transluminal Coronary
Angioplasty
and stent.
Directional Coronary Atherectomy
(DCA).

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


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
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.




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.


1- Percutaneous Transluminal
Coronary Angioplasty ( PTCA)

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.




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



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


Rotablation
tip spins at high speed to
grind plaque away


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.

5. Cutting Balloon


6. Transmyocardial Laser
Revascularization (TMLR):

The C0
2
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 Cont.
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.

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



Coronary Artery Bypass
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 Bypass
Saphenous 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 Management
Preoperative
Obtain the clients 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 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.


Nursing Management Cont.
Assess the clients fluid status frequently
during immediate postoperative period.

Note the clients level of consciousness,
neurologic status, ability to move.

To prevent infection during changing a
clients 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