Atherectomy

Atherectomy is an invasive interventional procedure that involves the removal of the atheroma, or plaque,
from a coronary artery by cutting, shaving, or grinding (Urden, et al., 2006). It may be used in conjunction
with PTCA. Directional coronary atherectomy and transluminal extraction catheter procedures involve the
use of a catheter that removes the lesion and its fragments. Another procedure called rotational
atherectomy uses a catheter with diamond chips impregnated on the tip (called a bur) that rotates like a
dentist’s drill at 130,000 to 180,000 rpm, pulverizing the lesion. Usually, several passes of these catheters
are needed to achieve satisfactory results. Postprocedural patient care is the same as for a patient after
PTCA.
Brachytherapy
PTCA and stent implantation cause a cellular reaction in the coronary artery that promotes proliferation of
the intima of the artery, increasing the possibility of arterial obstruction. Brachytherapy reduces the

recurrence of obstruction, preventing vessel restenosis by inhibiting smooth muscle cell proliferation.
Brachytherapy involves the delivery of gamma or beta radiation by placing a radioisotope close to the
lesion. The radioisotope may be delivered by a catheter or implanted with the stent. However, drug-
eluting stents are used more commonly to prevent restenosis, because they are typically more effective
and less expensive than brachytherapy (Reynolds, et al., 2007).
Complications
Complications that can occur during a PCI procedure include dissection, perforation, abrupt closure, or
vasospasm of the coronary artery, acute MI, acute dysrhythmias (eg, ventricular tachycardia), and cardiac
arrest. These may require emergency surgical treatment. Complications after the procedure may include
abrupt closure of the coronary artery and vascular complications, such as bleeding at the insertion site,
retroperitoneal bleeding, hematoma, and arterial occlusion, as well as acute renal failure (Table 28-4)
(Lins, Guffey, VanRiper, et al., 2006).
Postprocedure Care
Patient care is similar to that for a diagnostic cardiac catheterization (see Chapter 26). Patients who are
not already hospitalized are admitted the day of the PCI. Those with no complications go home the next
day. When the PCI is performed emergently to treat ACS, patients usually go to a critical care unit and
stay in the hospital for a few days. During the PCI, patients receive IV heparin or a thrombin inhibitor (eg,
bivalirudin [Angiomax]) and are monitored closely for signs of bleeding (Levine, Berger, Cohen, et al.,
2006). Patients may also receive a GP IIb/IIIa agent (eg, eptifibatide) for several hours following the PCI
to prevent platelet aggregation and thrombus formation in the coronary artery. Hemostasis is achieved,
and femoral sheaths may be removed at the end of the procedure by using a vascular closure device (eg,
Angio-Seal, VasoSeal) or a device that sutures the vessels. Hemostasis after sheath removal may also
be achieved by direct manual pressure, a mechanical compression device (eg, C-shaped clamp), or a
pneumatic compression device (eg, FemoStop).
Patients may return to the nursing unit with the large peripheral vascular access sheaths in place. The
sheaths are then removed after blood studies (eg, activated clotting time) indicate that the heparin is no
longer active and the clotting time is within an acceptable range. This usually takes a few hours,
depending on the amount of heparin given during the procedure. The patient must remain flat in bed and
keep the affected leg straight until the sheaths are removed and then for a few hours afterward to
maintain hemostasis. Because immobility and bed rest may cause discomfort, treatment may include
analgesics and sedation. Sheath removal and the application of pressure on the vessel insertion site may
cause the heart rate to slow and the blood pressure to decrease (vasovagal response).
An IV bolus of atropine is usually given to treat this response. Some patients with unstable lesions and at
high risk for abrupt vessel closure are restarted on heparin after sheath removal, or they receive an IV
infusion of a GP IIb/IIIa inhibitor. These patients are monitored closely and may have a delayed recovery
period. After hemostasis is achieved, a pressure dressing is applied to the site. Patients resume self-care
and ambulate unassisted within a few hours of the procedure. The duration of immobilization depends on
the size of the sheath inserted, the amount of anticoagulant administered, the method of hemostasis, the
patient’s underlying condition, and the physician’s preference. On the day after the procedure, the site is
inspected and the dressing removed. The patient is instructed to monitor the site for bleeding or
development of a hard mass indicative of hematoma.