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SHRI G.S. INSTITUTE OF
TECHNOLOGY & SCIENCE
(AN AUTONOMOUS
INSTITUTION ESTABLISHED IN 1952)
DEPARTMENT OF BIO MEDICAL ENGINEERING
REPORT
ENDOSCOPY AND
ANGIOPLASTY
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SUBMITTED TO:-
SUBMITTED BY:-
Mrs. VIBHA BHATNAGAR
AB~39001 ADITYA GUPTA
AB~39004 ASHISH ADWANI
Foreign Body Extraction
General
A variety of foreign bodies may accidentally or intentionally enter the gastrointestinal
(GI) tract. In about 90% of cases, however, they spontaneously pass out through the
GI tract. The remaining 10% comprise sharp, pointed, or bulky objects, which can
cause local trauma or chemical damage to the mucosa. Nearly all such foreign bodiescan be extracted with a flexible endoscope.
Indications
An emergency indication for endoscopic extraction is an impacted foreign object.
Acute obstruction of the esophageal lumen can cause aspiration pneumonitis or
pressure on the esophageal wall resulting in perforation and mediastinitis. Foreign
objects can become impacted in the esophagus at the three physiologic levels of
narrowing: the cricopharyngeal sphincter, aortic arch, and diaphragmatic hiatus.Objects that reach the stomach and are likely to pose a risk of mechanical or toxic
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injury should also be removed without delay. In addition, objects that remain in the
stomach for more than 72 hours should undergo early endoscopic extraction since
their spontaneous passage is unlikely. A bezoar requires debulking by endoscopic
fragmentation to facilitate its removal.
Prerequisites
Prior to endoscopic extraction of a foreign body, information regarding the type,
form, and size of the foreign body is required to plan the strategy of removal and to
select the instruments to be used. A plain radiograph of the upper GI tract may not
always adequately localize the foreign body, and therefore a contrast study may be
necessary. If a perforation is suspected, a water-soluble contrast agent like
Gastrografin is preferred.
The colon may also require evaluation with a contrast enema study. If an esophageal
foreign body is suspected, then a plain radiograph of the chest should also include theneck as it is not unusual for foreign bodies to impact at the cricopharyngeal sphincter.
Children and uncooperative adults often require general endotracheal anesthesia so
that the procedure can be carried out safely and successfully.
Figs. 16)
Fig. 1a, b Extraction of a coin from the esophagus. a In children, a coin often impactsat the level of the cricopharyngeal sphincter.
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b A coin with an elevated edge is easy to grasp and extract with the rat-tooth forceps.
Coins with a smooth edge can be grasped with rubber-coated prongs.
Instruments
Apart from pediatric and therapeutic upper endoscopes, the endoscopic
armamentarium should include a variety of forceps (crocodile, rat-tooth, etc.), snares,
Dormia baskets, and a long overtube.
Technique
An overtube is recommended when removing pointed or sharp objects to avoid
damage to the esophagus and pharynx. Small or slippery objects should also be
removed through an overtube. It is safest to insert the overtube over a guidewire,
using an appropriately sized bougie (generally 45-French) as an obturator. If the
foreign body occludes the lumen completely and prevents guidewire placement, then
the overtube can be preloaded over the endoscope and pushed into place after the
endoscope has been inserted across the pharynx. In such a case, a therapeutic
gastroscope should be used to reduce the step formation between the endoscope and
the overtube.
Complications
Perforation is the most serious complication that can result from endoscopic foreign
body extraction. This usually occurs when removal is difficult or requires excessive
force. As
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a rule, objects obstructing the esophageal lumen should not be pushed into the
stomach. Sharp or pointed objects that can lacerate the mucosa should always be
removed through
an overtube. Injury to the GI wall, whether due to pressure necrosis, a tear, or a
difficult extraction, should be promptly investigated with a radiographic contrast
study using a watersoluble contrast agent to rule out a perforation. The possibility of adelayed perforation caused by tissue necrosis should also be kept in mind. Dietary
restrictions and acidsuppressive or mucosa-protective drug therapy may be indicated,
and the patient (or responsible next of kin) should be informed about the risk of
delayed perforation. The risk of a foreign body aspiration during extraction also
deserves emphasis. Apart from using an overtube, endotracheal intubation is
recommended for patients at increased risk for aspiration. This also includes the
patient who is not fasting and particularly if intravenous sedatives are administered
prior to the endoscopic procedure.
Bougienage and Balloon Dilation
General
Bougienage or pneumatic dilation is commonly performed for the treatment of benign
and malignant strictures of the esophagus, and occasionally for pyloric or colonic
strictures. Biliary and pancreatic duct strictures are also amenable to dilation.
Repeated dilation is usually necessary to achieve a satisfactory long-term therapeuticresult.
Indications
The main indication is a benign, fibrotic stricture of the esophagus. The etiology is
usually peptic (recurrent reflux esophagitis) or postoperative (anastomotic stricture).
Bougienage is also often indicated prior to stent placement for malignant strictures ofthe esophagus or bile duct. Benign strictures of the bile duct (postoperative, sclerosing
cholangitis) and pancreatic duct (chronic pancreatitis, posttraumatic) are candidates
for bougienage or pneumatic dilation if the stricture is short (see Chapter 11, Biliary
Stent Drainage, and Chapter 12, Pancreatic Duct Stenting and Stone Extraction).
Stenoses in other locations (pylorus, rectum, colon, or gastrointestinal [GI] and
biliodigestive anastomoses) are less common indications that require a further workup
before general recommendations can be made. The role of endoscopic dilation for
strictures of chronic inflammatory diseases such as Crohns disease and diverticulitis
needs to be assessed on a patient-to-patient basis, taking into account the endoscopic
and radiographic findings and the riskbenefit ratio as compared with surgical
options. Pneumatic dilation is an alternative to surgical cardiomyotomy for thetreatment of achalasia. Repeated dilations are usually required. Intramural injection of
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botulinum toxin is an endoscopic alternative that may achieve results similar to those
of pneumatic dilation.
Prerequisites
A preliminary radiographic contrast study is recommended to provide an anatomic
road map. A small-diameter gastroscope is used for the initial evaluation. Biopsies
are
obtained to determine the nature of the stricture. Since a negative biopsy does not rule
out malignancy, repeat biopsies may be required after dilation before a stricture can
be labeled as benign. The majority of benign strictures require repeated sessions of
dilation over a prolonged period of time. Patient education and compliance are
therefore important requirements of endoscopic therapy. Patient compliance can be
enhanced by minimizing the level of procedural discomfort. Most dilation procedurescan be performed under intravenous sedation on an outpatient basis. Procedures are
initially repeated at 3- to 4-day intervals and then at 2- to 3- week intervals.
Perforation is the most common and dangerous complication that can follow
bougienage or pneumatic dilation. Appropriate patient selection, correct choice of
instruments, and a cautious technique are the key factors in avoiding perforation.
Fig. 20 Dilation over a hydrophilic guidewire is possible with small-diameter bougies
(up to 30-French). The stricture should be inspected after dilation with a small-
diameter endoscope to rule out deeper tears.
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Fig. 21a, b The hydrophilic guidewire, which is not as stiff as the metal guidewire, is
not suited for bougienage of tight or infiltrating strictures. a A radiopaque 9-French
catheter is inserted over the hydrophilic guidewire, through which the hydrophilic
wire is exchanged for the more rigid Eder-Puestow wire.
Instruments
The most widely used bougies for esophageal dilation are the flexible Savary-Gilliard
bougies made of PVC (polyvinyl chloride). These come in diameters ranging from5 to
20 mm. Bougies made of stiffer plastic material may occasionally be required for
extremely tight or infiltrating strictures. The diathermic needle knife, the argon
plasma-coagulator,
or the Nd:YAG laser can be used to incise fibrotic ring strictures. TTC (through-the-channel) balloon dilators can be inserted through the biopsy channel of the endoscope
and are available in diameters ranging from 6 to 25 mm. Larger balloon dilators with
diameters of 30, 35, and 40 mm, which are used for the treatment of achalasia, are
inserted over a guidewire. An alternative to the balloon dilator is a balloon that is
attached to the end of the endoscope. In contrast to balloon dilators, which are made
of low-compliance plastic polymers, the balloon attached to the endoscope is made of
latex rubber and consists of three layers. Biliary and pancreatic duct strictures can be
dilated with Teflon dilators or hydrostatic balloons . Bougienage of strictures initially
entails the placement of a Savary-Gilliard guidewire across the stricture through the
biopsy channel of the endoscope. The wire is available with or without calibrations,
the former wire being mandatory if dilation is performed without fluoroscopy.Hydrophilic guidewires commonly used for the biliary and pancreatic ducts (260 cm
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long, 0.035 or 0.038 in, J-shaped tip) are also used for negotiating long, tight, and
tortuous strictures.A pediatric endoscope (outer diameter of 5.3 or 7.9 mm) may be
necessary to pass a tight or difficult stricture.
Technique
Bougienage should always be performed over a guidewire. Therefore, proper
placement of the guidewire is the key to a successful and safe procedure. Balloon
dilation with smaller TTC balloons are performed under direct endoscopic guidance.
The choice of the balloon or size of the dilator depends upon the tightness of the
stricture. This can be judged by the radiologic and endoscopic appearance of the
stricture and the resistance encountered during passage through the stricture.
Esophageal Stent
Placement
General
Esophageal stenting palliates obstructive symptoms caused by tumors of the
esophagus and the cardia. Stent placement not only relieves dysphagia, thus enabling
oral nutrition, but also prevents aspiration pneumonitis. Tracheoesophageal fistulae,
too, can cause similar complications. The major advantage of stent placement over
other palliative treatments is the prompt relief of dysphagia.
Indications
The primary indications are dysphagia and tracheoesophageal fistulae due to
advanced, unresectable, or inoper-able tumors of the esophagus and cardia. Less
scommon indications are strictures at other sites, such as the distal stomach or rectum,
that fulfill criteria in which palliative surgery is either not feasible or too hazardous.
Prerequisites
Fundamental prerequisites for stent placement are confirmation of malignancy on
biopsy and unresectability on imaging studies. The palliative objectives should be
well defined
and the symptoms should correspond to findings on radiologic and endoscopic
imaging (including endosonography and bronchoscopy). Despite the larger diameter
of self-expandable metal stents, palliation of dysphagia may not be superior.
Peristalsis
an important component of swallowingis impaired by the tumor as well as the stent.
Thus, a larger stent diameter may not necessarily enhance the patients ability toswallow.
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A reasonable goal of treatment is the ability to swallow a soft pureed diet, for which
an inner stent diameter of 10mm usually suffices. In the literature plastic stent
placement has been complicated by high perforation rates, partly due to the need for
extensive bougienage prior to stenting. Selecting a plastic stent with a smaller
diameter (10 mm), soft material, and proper technique (see following text, Technique)
will minimize the risk of perforation. Plastic and expandable stent placement requirespreliminary dilation of the tumor stenosis. To avoid perforation, bougienage should be
performed gradually and, if necessary, in several sittings. Excessive dilation should be
avoided to prevent subsequent migration of the stent.
Fig. 34 Instruments for plastic stent placement: bougie with the Savary-Gilliard
guidewire, transparent pusher tube with markings in centimeters, and a plastic stent.
Instruments
A variety of plastic (silicon, latex, Tygon) and self-expanding metal (stainless steel,
nitinol) stents are available for the treatment of tumors obstructing the esophagus
and/or cardia . Self-expandable stents are covered to prevent tumor ingrowth. The
expandable stents differ in their expansile force, flexibility, release mechanisms,
radiographic visibility, and retrievability. Expandable stents equipped with anti-reflux
mechanisms (valve, windsock) have been designed for low esophageal or cardia
strictures. Plastic stents may need to be modified to accommodate special anatomic
situations. For cervical esophageal strictures a stent with a short funnel and a small
diameter (outer diameter of less than 10 mm) is used to avoid or minimize foreign
body sensation and tracheal compression. For distal esophageal or cardia strictures a
stent with distal flaps to prevent proximal migration is used (Fig. 33). To seal off a
fistula, a stent with a wide funnel is used (this can be achieved by adding a second
funnel). Silicone flaps and a second funnel are added to the stent with a fast-acting
glue. Fluoroscopy is required to guide expandable stent placement, but is not
mandatory for the insertion of a plastic stent. A 29-French bougie serves as an
introducer for a stent with an internal diameter of 10 mm, inserted over a Savary-
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Gilliard guidewire. The stent is advanced with a 14- mm calibrated pusher tube (Fig.
34).
Percutaneous EndoscopicGastrostomy (PEG)
General
Percutaneous endoscopic gastrostomy (PEG) is the intentional formation of a
gastrocutaneous fistula for the purpose of enteral feeding. It has gained widespread
popularity because it is technically easy, rapid, and safe. It is preferable to nasoenteral
feeding tubes for long-term enteral feeding.
Indications
PEG is primarily indicated in patients who are unable to swallow. The causes are
usually neurogenic impairment or obstructive tumors of the oral cavity. Less
commonly, PEG
may be indicated for nutritional support of the undernourished patient with gross
anorexia.
Prerequisites
Percutaneous transgastric nutrition requires a patent bowel. This can usually be
determined from the patients history. Gastric outlet obstruction should be ruled out
on an upper gastrointestinal (GI) endoscopy. Residual food or secretions
in the stomach or duodenum in the fasting patient signal the possibility of outletobstruction. Stenoses in the oropharynx and esophagus may require a preliminary
bougienage. An absolute prerequisite for PEG is a close contact between the anterior
wall of the stomach and the abdominal wall. Interposed viscera are excluded by
transillumination through the abdominal wall with the endoscope. Hepatomegaly can
also impede PEG and is excluded by physical examinationPortal hypertension
increases the risk of bleeding during PEG and should consequently bewatched out for
and tested for. Preoperative broad spectrum antibiotics are generally recommended as
a prophylaxis against infection. The abdomen is prepared and draped as for an
abdominal operation. The key to avoiding complications is proper postoperative
careespecially during the firstweekuntil the parietal and visceral peritoneum have
fully adhered. Tube feeding can be started on the same day as placement if the tube isproperly positioned and anchored.
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Fig. 42 Assuming normal GI anatomy, the puncture site is approximately 23
fingerbreaths under the left costal margin in the paramedian line. In the patient with a
Billroth II operation, the puncture site is along the left costal margin.
Instruments
Gastrostomy sets differ according to the technique used. The pull technique is the
most commonly used. In general, a 15- French feeding tube is adequate for instilling
commercially available enteral nutrition preparations. Most PEG tubes have an
internal bolster measuring approximately 2.5 cm in diameter and can be fixed to the
abdominal wall by an adjustable external bolster. Antiseptic solution, scalpel, gauze
dressing, and various adaptors for the feeding tubes are usually supplied in most
commercially available kits. A special 110-cm-long 9-French tube is also available for
placement in the jejunum (percutaneous endoscopic jejunostomy). PEG is performed
using a standard diagnostic gastroscope with a 2.8-mm working channel. The thread
can be grasped with a biopsy forceps or polypectomy snare. A rattooth forceps is
necessary for placing a jejunal feeding tube.
Technique
In the more popular pull technique, the PEG tube is pulled through the oropharynx
with the aid of an attached thread that pulls it out through the stomach and abdominal
wall.
Using the push technique, the tube is percutaneously inserted directly into the
stomach over a guidewire. Although the push technique is a more direct approach, it
requires serial dilation of the puncture tract to allow insertion of the PEG tube and is
thus more complicated and involves more risk than the pull technique. The procedure
begins with a standard esophagogastroduodenoscopy in the left lateral position.
Stomach contents are cleared with endoscopic suction.
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Enteral Tube Placement
General
Tubes are endoscopically placed into the jejunum either to enable enteral feeding or todecompress the small bowel. A tube can also be inserted into the colon to decompress
it.
Indications
A jejunal tube is indicated for enteral feeding when gastric emptying is impaired
because of mechanical obstruction or a motility disorder. Long-term jejunal feeding
warrants a percutaneous endoscopic gastrostomy (PEG) through which the feeding
tube is inserted. A jejunal tube is also indicated for small-bowel decompression in
patients with unclear intestinal obstruction (e.g., ileus in the early postoperative
phase). Tube decompression
of the colon is indicated for colonic pseudo-obstruction.
Prerequisites
Bowel decompression should not be an excuse for postponing a necessary operation.
This applies particularly to mechanical intestinal obstruction. Distal propagation of
the
Dennis tube requires at least some peristaltic activity. In the setting of a complete
adynamic ileus, a Dennis tube is no better than a nasogastric tube. Endoscopicdecompression of colonic pseudo-obstruction is indicated when the risk of surgery is
considered to be prohibitively high.
The feeding tube is advanced under direct vision into the jejunum. The wire is then withdrawn until it lies
about 5 cm beyond the endoscope. This will prevent the tube from kinking.
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Instruments
A pediatric gastroscope (outer diameter 5.9mm or 7.9 mm) is used to position a
guidewire for over-the-wire insertion of an enteral tube. A therapeutic gastroscope
with a 3.7-, 4.2-, or 6-mm working channel is used for through-the-scope (TTS)
placement of enteral tubes. A variety of enteral tubes are available: Feeding tube: 250 cm long, 9-French, with adapter
Dennis tube for small-bowel decompression: 210 cm long, 16-French triple-lumen
tube with a balloon at the tip
Colonic decompression tube: 130 cm long, 24-French polyethylene tube inserted
over a 300 cm long, 7-French radiopaque Teflon delivery catheter
Accessories required are Teflon-coated stainless steel and hydrophilic guidewires
(400 cm long, 0.035 in) and a large rat-tooth forceps to grasp the Dennis tube and
advance it into the duodenum.
Technique
The TTS technique is the easiest and fastest method of placing feeding tubes. A 9-
French feeding tube, stiffened with a0.035-in Teflon-coated guidewire, can be
inserted through a gastroscope with a 3.7-mm working channel (Fig. 60). Overthe-
wire placement is performed if a large-channel gastroas
ANGIOPLASTY
What is angioplasty?
What is the benefit of having angioplasty? What causes blockages in the arteries?
Why do I need angioplasty?
What should I expect before my angioplasty?
What happens during my angioplasty?
What should I expect after the procedure?
What is angioplasty?
Angioplasty is a minimally-invasive procedure that repairs and restores blood flow
through a narrowed or blocked artery in the heart. The procedure is performed by aninterventional radiologist.
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What is the benefit of having angioplasty?
Angioplasty can prevent a heart attack or stoke by opening your blocked artery,
restoring blood flow to your tissues and relieving your symptoms without the need for
surgery.
What causes blockages in my arteries?
Blockages in arteries and veins can be caused by smoking, high cholesterol levels,
diets high in saturated fats, and cardiovascular disease.
Why do I need angioplasty?
The most common reason for angioplasty is to relieve a blockage of an artery caused
by atherosclerosis, or hardening of the arteries. Atherosclerosis is a gradual process in
which cholesterol and other fatty substances in the bloodstream form a substancecalled plaque on the inside of the blood vessel walls and clog the artery. When
medications or lifestyle changes arent enough to reduce the effects of blockages in
your arteries, or if you have worsening chest pain or heart problems your doctor may
suggest angioplasty. If you have extremely hard plaque deposits, blockages, or blood
vessel spasms that dont go away, you probably are not a good candidate for
angioplasty.
What should I expect before my angioplasty?
Prior to the procedure, you may have several tests performed, such as X-rays and
blood tests. You will be asked not to eat or drink anything after midnight the nightbefore your procedure. You should tell the interventional radiologist or nurse if you
are allergic to any medications. Angioplasty usually requires an overnight hospital
stay. Make sure you arrange for transportation home.
What happens during my angioplasty?
Angioplasty is performed by a specially-trained doctor, called an interventional
radiologist.
The interventional radiologist will use an intravenous (IV) line to give you fluids andmedicines that will relax you and prevent blood clots. Next the nurse will:
Shave the area where the catheter or tube will be inserted, usually the arm or
groin.
Clean the shaved area to make it germ free.
Numb the area.
When you are comfortable, the interventional radiologist will begin the procedure.
A small incision is made in the skin to find an artery. The doctor then threads
a very thin wire through the artery up to the coronary artery that is blocked.
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When the wire reaches the area of the blockage, a tube (called a catheter) with
a deflated balloon on the end is threaded into the blocked artery under X-ray
guidance.
A small amount of dye may be injected through the tube into the blood stream
to help show the blockage on X-ray. This X-ray picture of the heart is called
an angiogram. When the tube reaches the blockage, the balloon is inflated. The expanding
balloon forces the blockage to open by pushing the walls of the artery
outward, increasing blood flow to the heart muscle.
A stent usually is placed at the site to keep the artery open. Once the balloon
has been deflated and withdrawn, the stent remains in place permanently,
holding the blood vessel open and restoring blood flow to the arteries.
What should I expect after my procedure?Your catheter site will be checked for bleeding and swelling after the procedure. Your
blood pressure and heart rate will be monitored. Your physician may prescribe
medication to relax you and protect your arteries against spasm and to prevent blood
clots. Usually you will stay at the hospital overnight and return home the day after the
procedure. You typically will be able to walk within two to six hours following the
procedure and return to your normal routine by the following week.
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The Facts on Angioplasty
Angioplasty is a technique for reopening narrowed or blocked arteries in theheart (coronary arteries) without major surgery. First used in 1977, it's now as
common as heart bypass surgery. It's sometimes called percutaneous transluminal
coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI).
"Angio" means relating to a blood vessel and "plasty" means repair. Angioplasty is
also used in other parts of the body, usually to treat peripheral artery disease.
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Before the operation
You shouldn't eat after midnight on the night before your angioplasty. Ask your
doctor if you can drink clear liquids after this. You can usually continue to take yourmedications, but you should discuss this with your doctor. Check with your doctor if
you take blood thinners such as warfarin, as you may need to stop them 5 days before
the procedure. If you take insulin, you may have to adjust the dose.
You must also tell your doctor if you are allergic to iodine or shellfish, since
angioplasty involves injecting you with an iodine-based dye. You may have to go for
some preliminary blood tests. Your doctor may tell you to not smoke for a period of
time before or after angioplasty. For best results, you should quit smoking
permanently.
The procedure
Angioplasty is performed while you are awake, under local anesthetic. It's sometimes
uncomfortable, but not usually painful. The surgeon makes a small incision in the
groin or arm and inserts a thin tube, called a catheter, into the artery. The catheter
includes a small balloon and a small wire tube, called a stent. Once the catheter is in
place, a dye is injected and X-rays are taken, which tell the physician exactly where
the blockages are and how narrow the artery is. This is also known as an angiogram
and functions as a map for the doctor.
The doctor will then inflate the balloon, opening the stent and pushing it against theartery wall. After the procedure is complete, the cells that line the blood vessel will
grow around the stent, holding it in place. The whole procedure usually lasts 30
minutes but may last as long as several hours. Sometimes, people will have to return
to get their arteries redone because of renarrowing (restenosis) at the site of the
balloon inflation.
There are other types of angioplasty sometimes used in combination with the
balloon:
Drug-coated stents are specially-treated stents that gradually release a special
medication into the wall of the artery after they have been put into place and
inflated. They reduce the risk of needing another procedure and are used for
people who have a high risk of developing renarrowing of the artery after the
initial procedure. These stents may increase the rare risk of clotting. Studiesare ongoing to identify safety and outcomes of the use of these stents.
Directional atherectomy involves using a miniature rotating blade to cut out
the fatty deposit and remove it from the body.
In rotational atherectomy, a diamond-studded drill bit is used to pulverize
tough blockages.
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Intracoronary radiation involves irradiation of the section of artery after
balloon angioplasty. Studies show this experimental technique reduces
restenosis in your artery by 70%.
After the operation
Most people are admitted to hospital and monitored overnight after angioplasty.They are usually sent home early the next day.
Once home, avoid any type of lifting or other strenuous physical activity for a week.
Your doctor will advise you when you will be able to return to work and resume
driving and other physical activity.
If you have a stent, you will usually have to take an extra blood thinner medication
such as clopidogrel in addition to acetylsalicylic acid for at least the first few months
in order to prevent blood from clotting on the metal stent. This treatment may
continue for one year. You may also have to put off dental work for several months
due to the risk ofendocarditis (an infection of the heart).
Call your doctor if you:
experience swelling, bleeding, or pain at the insertion site
develop a fever
notice a change in temperature or colour in the arm or leg that was used
feel faint or weak
have shortness of breath or chest pain
Angioplasty or coronary arteries bypass surgery?
Coronary artery bypass grafting (CABG) is a successful but more invasive technique
for restoring blood flow to the heart. The heart is usually stopped and chilled, and the
patient is kept alive by a heart-and-lung machine. Usually strips of vein are removed
from one or both of the patient's own legs to be used as bypass grafts.
The great advantage of angioplasty is that the artery is returned to normal size without
resorting to major surgery. The drawback to angioplasty is restenosis. This is when
the artery renarrows due to scar formation and possibly further plaque formation. If
the angioplasty lasts six months, there's a good chance it's permanent, but restenosis is
far more likely after angioplasty than after a CABG.
On the other hand, angioplasty allows people to come back for more treatment. If an
artery re-narrows after CABG, there may not be enough vein or artery segments
elsewhere in the body to perform a second graft. Moreover, a second angioplasty is
far less traumatic to the body than a second open heart procedure.
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Sometimes, circumstances will make the choice for you. People with many severe
blockages, multiple coronary blockages, or those who have diabetes may be better off
with CABG. Also, most hospitals don't perform angioplasty if there are several major
arteries blocked. This is because angioplasty temporarily blocks the artery completely
when the balloon is inflated. If the other arteries are also blocked, this could trigger a
heart attack. However, if you're over 80 years of age or have other serious medicalproblems, you may be considered too vulnerable for the trauma of open-heart surgery.
In that case, angioplasty may be a more attractive option, no matter how many arteries
are blocked.
Possible complications
Angioplasty is safer than bypass surgery. Less than 1% of people die from
complications of angioplasty. Non-fatal serious complications occur in 1% to 5% of
people who undergo this procedure. These complications include:
tearing of the lining of the artery resulting in total blockage and possible heart
attack - this can usually be repaired with a stent
stroke from a clot that is dislodged while the catheter is inside the body
bleeding or bruising
kidney problems, especially in people with underlying kidney disease and
diabetes - this is caused by the iodine contrast dye used for the X-ray;
intravenous fluids and medications can be given before and after the procedureto try to reduce this risk
All medications have both common (generic) and brand names. The brand name is
what a specific manufacturer calls the product (e.g., Tylenol). The common name is
the medical name for the medication (e.g., acetaminophen). A medication may have
many brand names, but only one common name. This article lists medications by their
common names. For more information on brand names, speak with your doctor or
pharmacist.
What Are the Risks of Coronary Angioplasty?
Coronary angioplasty is a common medical procedure. Serious complications don't
occur often. However, they can happen no matter how careful your doctor is or how
well he or she does the procedure. Serious complications include:
Bleeding from the blood vessel where the catheters were inserted.
Blood vessel damage from the catheters.
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An allergic reaction to the dye given during the angioplasty.
An arrhythmia (irregular heartbeat).
The need for emergency coronary artery bypass grafting during the procedure
(24 percent of people). This may occur if an artery closes down instead of
opening up.
Damage to the kidneys caused by the dye used. Heart attack (35 percent of people).
Stroke (less than 1 percent of people).
Sometimes chest pain can occur during angioplasty because the balloon briefly blocks
blood supply to the heart.
As with any procedure involving the heart, complications can sometimes, though
rarely, cause death. Less than 2 percent of people die during angioplasty.
The risk of complications is higher in:
People aged 75 and older
People who have kidney disease or diabetes
Women
People who have poor pumping function in their hearts
People who have extensive heart disease and blockages in their coronary
(heart) arteries
Research on angioplasty is ongoing to make it safer and more effective, to prevent
treated arteries from closing again, and to make the procedure an option for more
people.
Complications From Stents:
Restenosis
After angioplasty, the treated coronary artery can become narrowed or blocked again,
often within 6 months of angioplasty. This is called restenosis (RE-sten-o-sis). Whena stent (small mesh tube) isn't used during angioplasty, 4 out of 10 people have
restenosis.
The growth of scar tissue in and around a stent also can cause restenosis. When a stent
is used, 2 out of 10 people have restenosis.
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Stent Restenosis
The illustration shows the restenosis of a stent-widened coronary artery. In figure A,
the expanded stent compresses plaque, allowing normal blood flow. The inset image
on figure A shows a cross-section of the compressed plaque and stent-widened artery.In figure B, over time, scar tissue grows through and around the stent. This causes a
partial blockage of the artery and abnormal blood flow. The inset image on figure B
shows a cross-section of the tissue growth around the stent.
Stents coated with medicine reduce the growth of scar tissue around the stent and
lower the chance of restenosis even more. When these stents are used, about 1 in 10
people has restenosis.
Other treatments, such as radiation, can help prevent tissue growth within a stent. For
this procedure, a wire is put through a catheter to where the stent is placed. The wirereleases radiation to stop any tissue growth that may block the artery.
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Blood Clots
Studies suggest that there's a higher risk of blood clots forming in medicine-coated
stents compared to bare metal stents. However, no conclusive evidence shows thatthese stents increase the chances of having a heart attack or dying, if used as
recommended.
When medicine-coated stents are used in people who have advanced CHD, there is a
higher risk of blood clots, heart attack, and death. Researchers continue to study
medicine-coated stents, including their use in people who have advanced CHD.
Taking medicine as prescribed by your doctor can lower your risk of blood clots.
People who have medicine-coated stents usually are advised to take anticlotting
medicines, such as clopidogrel and aspirin, for months to years to lower the risk of
blood clots.
As with all procedures, it's important to talk with your doctor about your treatment
options, including the risks and benefits.
Key Points
Coronary angioplasty is a procedure used to open blocked or narrowed
coronary (heart) arteries. The procedure improves blood flow to the heartmuscle.
Over time, a fatty substance called plaque can build up in your arteries,
causing them to harden and narrow. When plaque builds up in the coronary
arteries, the condition is called coronary heart disease (CHD).
Angioplasty can restore blood flow to the heart if the coronary arteries have
become narrowed or blocked because of CHD. The procedure can improve
symptoms of CHD, reduce damage to the heart muscle caused by a heart
attack, and reduce the risk of death in some patients.
Angioplasty is less invasive than surgery. General anesthesia isn't needed.
You'll be given medicines to help you relax, but you'll be awake during the
procedure. Before angioplasty is done, your doctor will need to know the location and
extent of blockages in your coronary arteries. To find this information, your
doctor will use coronary angiography. This test uses dye and special x rays to
show the insides of your coronary arteries.
Angioplasty is done in a special part of the hospital called the cardiac
catheterization laboratory.
During angioplasty, your doctor will use a thin, flexible tube called a catheter
with a balloon at the end. He or she will thread the balloon catheter through an
artery in your arm or groin (upper thigh) to the blockage in your coronary
artery. Your doctor will then inflate the balloon. This pushes the plaque
against the artery wall, relieving the blockage and improving blood flow.
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A small mesh tube called a stent usually is placed in the newly widened part of
the artery. The stent helps prevent the artery from becoming narrowed or
blocked again. The stent remains in place after the procedure.
After the procedure, you'll be moved to a special care unit. While you recover,
nurses will check your heart rate and blood pressure. Most people go home the
day after having angioplasty. Your doctor may recommend lifestyle changes after angioplasty to improve
CHD and to prevent arteries from becoming narrowed or blocked again.
Lifestyle changes may include changing your diet, quitting smoking, doing
physical activity regularly, losing weight or maintaining a healthy weight, and
reducing stress. You also should take all of your medicines exactly as your
doctor prescribes.
Angioplasty is a common medical procedure. Serious complications don't
occur often. However, they can happen no matter how careful your doctor is
or how well he or she does the procedure. Complications may include
bleeding, renarrowing of the artery, blood clots, and more.
Research on angioplasty is ongoing to make it safer and more effective, toprevent treated arteries from closing again, and to make the procedure an
option for more people.
Re-narrowing of your artery (restenosis). With angioplasty alone
without stent placementrestenosis happens in as many as 30 to 40 percent
of cases. Stents were developed to reduce restenosis. The original bare-metal
stents reduce the chance of restenosis to less than 20 percent, and the use of
drug-eluting stents has reduced the risk to less than 10 percent.
Blood clots. Blood clots can form within stents even weeks or months after
angioplasty. These clots may cause a heart attack. It's important to take
aspirin, clopidogrel (Plavix) and other medications exactly as prescribed to
decrease the chance of clots forming in your stent. Talk to your doctor about
how long you'll need to take these medications and whether they can be
discontinued if you need surgery.
Bleeding. You may have bleeding at the site in your leg or arm where a
catheter was inserted. Usually this simply results in a bruise, but sometimes
serious bleeding occurs and may require blood transfusion or surgical
procedures.
Other rare risks of angioplasty include:
Heart attack. Though rare, you may have a heart attack during the procedure.
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Coronary artery damage. Your coronary artery may be torn or ruptured
(dissected) during the procedure. These complications may require emergency
bypass surgery.
Kidney problems. The dye used during angioplasty and stent placement can
cause kidney damage, especially in people who already have kidney problems.
If you're at increased risk, your doctor may give you a medication to try toprotect your kidneys.
Stroke. During angioplasty, blood clots that may form on the catheters can
break loose and travel to your brain. Blood thinners are given during the
procedure to reduce this risk. A stroke can also occur if plaques in your heart
break loose when the catheters are being threaded through the aorta.
Abnormal heart rhythms. You heart may get irritated during the procedure
and beat too quickly or too slowly. These heart rhythm problems are usually
short-lived, but sometimes medications or a temporary pacemaker is needed.