One of the most important threats to the he alth of Poles is coronary artery disease, which is a disease caused, popularly speaking, by atherosclerosis. Today we are talking about the surgical treatment of coronary artery disease, i.e. angioplasty, with prof. Adam Witkowski, head of the Department of Cardiology and Interventional Angiology, Institute of Cardiology in Anin.
ProfessionallyPercutaneous coronary intervention (PCI) is a procedure aimed at dilation or restoration of a narrowed or closed coronary artery or previously implanted coronary artery bypass graft. The first percutaneous angioplasty using a balloon catheter (balloon angioplasty, classical) was performed by Dr. Andreas Gruentzig in 1977 in Zurich.
- Coronary angioplasty is a procedure that cleans the vessel caused by atherosclerotic changes. What exactly is it?
The procedure consists in puncturing the femoral artery in the groin or the radial artery in the wrist through the skin and inserting a catheter through this artery, which is then placed at the mouth of the coronary artery. Through this catheter, called the guiding catheter, after the coronary angiography, i.e. the contrasting of the corresponding coronary vessel and its visual assessment, a very thin coronary wire is inserted into the narrowed coronary artery, which, after passing through the stenosis site, is anchored on the circumference of the vessel. Then, a catheter with a balloon or a balloon and a stent placed on it is slid over this guide, i.e. a prosthesis made of a very thin metal mesh, usually covered with an anti-proliferative drug, which is filled with fluid under the appropriate pressure (usually 6-16 atmospheres or in the case of implantation) stent even more). After the procedure, the guidewire and balloon catheter are withdrawn from the coronary vessel and contrast is injected through the guide catheter to evaluate the effect of the procedure. When a stent is implanted, it remains permanently in the coronary artery. Apart from the metal ones, there are also completely biodegradable stents which after some time, usually within 1-3 years, completely "disappear" from the coronary vessel. After PCI, the arterial puncture site is closed with a pressure dressing or special closure devices. Other evaluation methods are also used during PCI proceduresstenosis or treatment effect, e.g., intracoronary ultrasound (ICUS), stenosis gradient measurement and partial flow reserve (FFR), or optical coherence tomography (OCT). All these methods require the introduction of additional probes or guides into the lumen of the coronary vessel.
- As you describe the procedure, it seems to be very difficult, complicated and takes a long time, in fact it is like that?
Percutaneous coronary angioplasty takes 40-60 minutes on average, but it depends on the complexity of the procedure, i.e. the number of coronary arteries that the operator intends to widen.
- Please tell me when and in what patients is angioplasty performed?
Percutaneous coronary angioplasty procedures are performed in patients with acute myocardial infarction and in those patients with stable angina, in whom pharmacological treatment is ineffective, and a significant (tight) stenosis of major or medium caliber of the coronary vessel. Often, in patients with stable angina, the so-called stress tests, also known as provocation tests, to confirm myocardial ischemia.
- What are these tests?
These tests include, for example, the exercise ECG test or the exercise test with the administration of an appropriate isotope (SPECT). The latter test also determines the size of the myocardial ischemia area, if it is greater than 10% of the entire area of the left ventricular muscle, the patient should be a candidate for percutaneous (PCI) or surgical (CABG) revascularization.
- How do cardiologists qualify patients for angioplasty? This is preceded by a series of detailed studies?
In patients with acute myocardial infarction, it is enough to assess the clinical condition of the patient - severe pain in the chest, often radiating to the lower jaw or forearm, and an ECG. In doubtful cases, the so-called indicator enzymes, usually troponin - their increase confirms the diagnosis of a heart attack. In patients with stable angina, a careful history, physical examination with blood pressure, ECG, often provocative tests, ECHO of the heart and coronary angiography are necessary. Only after such a comprehensive assessment can a decision be made whether the patient requires percutaneous coronary angioplasty, surgical revasparization, or should be treated conservatively.
- Angioplasty versus surgical revascarizationis much less invasive, and what is its effectiveness?
Usually very high, reaching 95-98% in the case of elective procedures. It may be lower in emergency cases, e.g. acute myocardial infarction, and especially a heart attack complicated by cardiogenic shock (then it is about 50%, but without an attempt to undertake angioplasty, the mortality reaches 100%).
- Angioplasty, however, is a procedure and it is certainly connected with some dangers and threats. What?
The most common but uncommon complications of percutaneous coronary angioplasty are local complications related to the puncture site of the femoral or radial arteries, such as subcutaneous hematoma or arterial thrombosis. In addition, serious complications such as myocardial infarction, acute renal failure, stroke, and death can also occur with elective PCI, these complications are very serious depending on the patient's clinical condition and age, the anatomy of the coronary tree, and the complexity of the atherosclerotic lesions in the coronary arteries. rarely, e.g. the risk of a stroke is lower than 1%, a heart attack around 0.5%, and death around 1%.
- What diseases are treated with angioplasty and which can be treated in the future?
PCI procedures are used to treat patients with all forms of coronary artery disease, and therefore mainly with acute coronary syndromes - acute myocardial infarction and unstable angina, and many patients with stable angina, the symptoms of which are chest pains cannot be controlled by drug treatment. Due to the continuous improvement of the technique of PCI procedures and better and better devices (e.g. stents) used in these procedures, many patients may now undergo PCI procedures in the case of stenosis of the main left coronary artery, and in some cases also in multivessel coronary disease. Bioresorbable stents, i.e. completely disappearing after some time after implantation from the coronary artery, are the next step in technological improvement and perhaps in the future they will further expand the indications for percutaneous coronary angioplasty.
- Professor, if not angioplasty, what alternative do doctors have?
An alternative is surgical revascarization (CABG), i.e. implantation by a cardiac surgeon of venous and / or arterial bypass grafts bypassing the site of coronary artery stenosis. Such an operation was introduced in 1966 by Dr. Rene Favaloro. Currently, such operations are also performed without the need for extracorporeal circulation and in selected patientscases where the sternum was not cut. Patients with stable angina can also be successfully treated conservatively for some time (pharmacological, dietary, physical rehabilitation).The text was written on the occasion of the IX Conference on Preventive Cardiology 2016 Krakow
Coronary angiography: examination of the coronary arteries
Coronary angiography is a highly specialized test that assesses blood flow through the coronary arteries. As this is a risky cardiac examination, it is only performed if there is a clear medical indication. Check how coronary angiography works. Source: "Operating room" (FOKUS TV)