Coronary Heart Disease (Rotablator + Atherectomy)

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What is it?

ATHRECTOMY

Atherectomy, as the name suggests, is excision or cutting of the plaque or blockade of the coronary arteries with the help of a special device which is passed from the groin vessels. The use of stenting and atherectomy has improved success rates most dramatically in the treatment of more complex lesions. As examples, calcified lesions respond well to rotational atherectomy, bifurcation lesions to directional atherectomy, and vein grafts to stenting.

Atherectomy, as the name suggests, is excision or cutting of the plaque or blockade of the coronary arteries with the help of a special device which is passed from the groin vessels. The use of stenting and atherectomy has improved success rates most dramatically in the treatment of more complex lesions. As examples, calcified lesions respond well to rotational atherectomy, bifurcation lesions to directional atherectomy, and vein grafts to stenting.

• DIRECTIONAL ATHERECTOMY- The directional atherocath is a device with a window in a cylinder that permits a circular cutting blade to excise tissue into a chamber in the catheter which can be removed.
  However a study, CAVEAT, has concluded that atherectomy alone in native coronary arteries does not lead to apparent benefit at six months or at one year.
  • Adjunctive balloon angioplasty - Current practice when atherectomy is used involves removal of significant tissue followed by balloon PTCA if atherectomy alone does not provide an ideal lumen with zero percent stenosis. The approach of following maximal tissue removal with adjunctive balloon post-dilatation in an effort to reduce the final residual stenosis to <15 percent is referred to as "optimal" atherectomy. The results with this approach are better than with atherectomy alone.
  • Use of intracoronary ultrasound - Intracoronary ultrasound (ICUS) is a new technology that allows in-vivo visualization of the coronary artery that has become particularly useful in further delineating plaque morphology and distribution.
  • Adjunctive therapy with abciximab - Directional atherectomy is associated with an increase incidence of MI, especially what is known as non-Q wave infarctions. By addition of a blood thinning drug called abciximab the rate of serious complications was significantly reduced.
• ROTATIONAL ATHERECTOMY - Rotational atherectomy is performed with a rapidly rotating olive-shaped ball with diamond chips which grinds calcified atheroma into small particles that can pass harmlessly through the distal myocardial capillary bed. This technique has been most useful for heavily calcified lesions which cannot be easily approached by balloon angioplasty or directional atherectomy. Concurrent use of stents may improve the long-term outcome in such lesions. As is true for directional atherectomy, rotational atherectomy can be followed by balloon PTCA to achieve a better final result.

Use for in-stent restenosis - Although atherectomy has the potential to dislodge or disrupt the stent rotational and directional atherectomy have been used successfully to treat diffuse in-stent restenosis. Rotational atherectomy leads to acute lumen gain as a result of effective removal of plaque while adjunctive PTCA produces additional lumen gain by further stent expansion and tissue extrusion. Prior to performing this procedure, however, some investigators recommend that intravascular ultrasound be obtained to determine whether restenosis is due to stent recoil or a tissue growth. The interest in atherectomy for the treatment of in-stent restenosis, however, has been reduced by the popularity of the "cutting balloon".

Any Interventional procedure would always include a cardiac catheterization. Cardiac catheterization is a test done in the Catheter lab to pinpoint the cardiac problem. Cardiac catheterization is a very safe procedure. Complications are so rare that it may be done on an outpatient basis. As with any medical procedure, though, there are risks.

How is it done?

Atherectomy is preceded by Cardiac catheterization. Cardiac catheterization is performed by a specially trained team of technicians, nurses, and doctors. A long, thin, flexible tube, a catheter, is inserted into a blood vessel in the arm or leg. A special type of x-ray screen, called a fluoroscope, shows the blood vessels and the heart so the doctor can guide the catheter into the correct position.

Heart pressures are measured inside the heart chambers. Samples of blood are taken through the catheter. Other tests depend on your particular problems.

X-ray studies are usually made during cardiac catheterization. Dye is injected through the catheter into different areas of the heart. One type, the coronary angiogram, shows blood flow through the coronary arteries to locate blockages. A ventriculogram shows the size and pumping action of the heart muscle, as well as the opening and closing of the heart valves. The electrical conduction system can also be tested to pinpoint the cause of irregular heartbeats and test how well the drugs are working to correct them.

If the procedure is done in a hospital, you will usually be admitted a day before the procedure. If you are allergic to shellfish or have ever had a reaction to x-ray dye, be sure to tell your doctor. The area where the catheter is inserted, usually the arm or the groin area, is shaved. You are not allowed to have anything to eat or drink 6 to 12 hours before the procedure.

Most people are a little nervous to learn that they will be awake during the procedure to follow the doctor's instructions. However, you should experience little discomfort. You are given a sedative before the procedure to help you relax. You will be monitored throughout the procedure.

Some procedure rooms may use tables that move from side to side while the x-rays are taken. In other rooms the table remains in one position while the camera moves around you. In either case, you are securely strapped to the table.

The area where the catheter is inserted is shaved and disinfected, and your arm or leg is strapped down. Sterile towels are placed over you to prevent infection. You usually cannot see what is occurring. After a local numbing medicine is injected, a small incision is made for the insertion of the catheter.

As the catheter is inserted, you will feel a slight pressure. At times during the procedure, the doctor may ask you to hold your breath, cough, and breathe deeply. You may also be asked to breathe oxygen. Medications may also be given during cardiac catheterization. Nitroglycerin is sometimes used to dilate the coronary arteries. If you heart's electrical conduction system is tested, you may be given drugs to speed up or slow down your beat.

Cardiac catheterization takes between 1 and 4 hours, depending on how many tests are performed.

When the x-ray dye is injected, you may experience a flushing sensation and nausea, but this will disappear quickly.

Atherectomy

Atherectomy may be done to improve blood flow to your heart. During this procedure, a catheter with a special grinding device is used. This device clears away the plaque in your blocked artery. After cardiac catheterization is done, a catheter called a guiding catheter is put into the blocked artery. A guide wire is then put through the guiding catheter. This wire is moved to the narrowed spot in your artery. The doctor watches the wire on the video screen. A special atherectomy catheter is threaded over the guide wire. The catheter is moved to the narrowed part of your artery.

The atherectomy catheter has a coarse burr near its tip. The doctor uses this burr to grind the plaque into very small bits. These bits float away in the bloodstream.

After the atherectomy, the doctor may do a balloon angioplasty. Angioplasty will compress any remaining plaque against the artery wall. Also, a stent may be placed. The catheters and guide wire are then removed. With the plaque reduced, blood flow to the heart muscle increases.

A stent is a small metal coil or mesh tube. After balloon angioplasty or atherectomy, a stent may be placed in the artery. This helps prevent the artery from narrowing again. The stent is mounted on a balloon-tipped catheter. The stent catheter is threaded over the guide wire. The catheter is moved to the part of the artery that was treated with balloon angioplasty or atherectomy. The balloon is inflated to open the stent. This also helps to further compress the plaque. When the stent is fully open, all catheters and the guide wire are removed. The stent stays in place. It helps prevent the artery from narrowing again (restenosis).

Your doctor may prescribe a 'blood thinning'(antiplatelet) medication for 2 to 4 weeks after the stent is in place. The medication helps prevent blood clots from forming on the stent. Your doctor may also suggest that you take aspirin life long to help prevent blood clots.

Why is it done?

The earlier description explains that these interventions are meant to restore the blood supply to muscles of heart affected by the blockages.

Precautions & Prerequisites

A complete workup is essential before the procedure. The workup will include serial ECG, Echocardiogram, blood tests, X-ray chest besides the angiogram. Patient is admitted to the hospital either night before or in the morning of the procedure. Patient has to remain fasting for 3-4 hours before the procedure. Depending on the procedure certain drugs may have to be started before the procedure. Please check with your doctor.In case you have a bleeding tendency, or allergies, do inform your doctor.

After all tests and procedures are done, you'll return to the cardiac care unit (CCU) or a special recovery room. There, you may need to remain lying down for a few hours. Depending on what procedures you had, you will go home the same day or stay overnight. Before you leave the hospital, your doctor will discuss the test results with you.

The sheath may be left in place for few hours to prevent bleeding. Sometimes a special plug, a stitch, or a pressure device is applied to the insertion site.

A nurse will regularly check your pulse and blood pressure. He or she will also check the insertion site for bleeding. While you are in the hospital, you'll remain connected to a heart monitor. An IV line may also continue to give you fluids and medications for a few hours.

Call the nurse if:

• You feel any chest pain or feel discomfort at the insertion site
• The arm or leg closest to the insertion site becomes numb or cold
• You feel warmth or wetness around the insertion site-a sign that you may be bleeding
• You have swelling near the insertion site

Recovery at home

Your doctor will talk to you about what to expect when you go home. He or she may also schedule return visits. When you leave the hospital, let someone else drive you home.

What to Expect

You may have a lump the size of an olive under your skin at the insertion site. There may also be a bruise. These are common problems which usually disappear on their own after a few weeks. You can go back to your normal activities a day or two after getting home. You will most likely be able to return to work within two weeks. Gradually increase your level of activity, don't overdo it. Get an OK from your doctor before you start exercising or doing heavy work.

Follow-up visits

See your doctor regularly for checkups. These visits help monitor your healing. In some cases, the treated artery may close up again. If this occurs, it is most likely to happen in the first 6 months after your procedure. Your doctor may do tests during this time. These tests check to see whether your artery is still open.

Call your doctor if you have:
Pain, swelling, redness, bleeding, or drainage at the insertion site.Angina, severe pain, coldness, or a bluish color in the arm or leg into which the catheters were inserted. Blood in your urine or black or tarry stools. Any bleeding if you are taking anti-platelet medication

Cardiac rehabilitation

Your doctor may refer you to a cardiac rehabilitation (cardiac rehab) program. This program helps you make changes that can improve your heart health. These changes also reduce your risk for future heart problems.

Support for change

Cardiac rehab program may begin while you're in the hospital. During cardiac rehabilitation, an expert helps you design a program to help you recover fast and stay healthy.

Do regular exercise to lower your blood pressure

• Quit smoking
• Control diabetes
• Lose excess weight
• Reduce stress
• Lower your cholesterol
• Learn to cope better with change

Getting exercise to help your heart

Like any muscle, your heart works better if it gets exercise. Exercise also reduces stress, lowers your cholesterol, and helps you lose excess weight. But talk with your doctor before you start exercising. He or she can make sure the activity you've chosen is right for you. In some cases, your doctor may suggest a cardiac rehab program for you instead. The tips below can help you start being active.

Tips for being active

Choose an activity that makes your lungs and heart work harder than they do when you rest. Do something you enjoy. Good choices are walking, dancing, swimming, bicycling, or aerobics.

Start slowly. Exercise 3 times a week for 5 to 10 minutes each time.When you feel comfortable, exercise a little more each week.Build up to exercising 4 or 5 times a week for 20 to 40 minutes at a time.Plan your exercises ahead of time. Write them on your calendar.If you get angina when you exercise, stop right away. Take your angina medication and call you doctor. Eating heart healthy food

Your doctor may suggest certain changes in the way you eat. The changes that are best for you will depend on your health problems and individual needs. But most people can improve their heart health by eating less fat and less salt. Start with the tips below.

Tips for Quitting:

• Make a firm decision to quit
• Find someone to quit with you. Or join a stop-smoking support group.
• Ask your doctor about aids such as nicotine patches, nicotine gum, or medications.
• Have carrot or celery sticks, gum or hard candies when you feel the urge to smoke.
• Make a list of the reasons why you're quitting. Read the list when you feel like smoking.
• Note daily routines that give you the urge to light up. Then change them if you can.