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Coronary Revascularization
Nursing Care- Complex Health Problems II (11-63-375)
University of Windsor
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Coronary Revascularization
Revascularization Procedures
Percutaneous coronary interventions (PCI)* Coronary artery bypass graft (CABG) o “On-pump” o “Off-pump” *the most commonly performed revascularization procedure
Indications
Activity-limiting symptoms despite maximal medical therapy Not tolerating medical therapy well Those with coronary anatomy for which revascularization has proven survival benefit, for example: o Significant left main disease o Multi-vessel disease o AMI
Percutaneous Coronary Interventions (PCI)
PCI – term collectively describing non-surgical procedures to restore or improve blood flow to myocardium. Examples: o Percutaneous transluminal coronary angioplasty (PTCA) o Intra-coronary stenting o Coronary atherectomy, thrombectomy, etc. Percutaneous transluminal coronary angioplasty (PTCA): Angioplasty with stent Drug-eluting stents o Slowly releases drug to block cell proliferation o Helps prevent re-stenosis Atherectomy Devices:
Indications
AMI (STEMI and non-STEMI) Stable/unstable angina High risk CABG candidates Contra-indications – diminished +++ as technology, techniques, and experience have advanced
Pre-Procedural Care
Labs – cardiac enzymes, ‘lytes (especially K), coagulation profile, creatinine, BUN, CBC Assess iodine, medication sensitivities, pre-op circulation (pulses) NPO; assure adequate hydration Sedatives; Aspirin; clopidogrel +/- other anti-platelets, anti-coagulants Patient teaching o purpose, answer questions, procedural and post-procedural expectations
Post-Procedural Care
Similar to that of cardiac catheterization (Table 34-5) Promote hemostasis with vascular closure device (specialized sutures, clips, patches) or manual/mechanical pressure Bedrest (supine with HOB ≤ 45°) with immobilized extremity x 2-6 hrs after sheath removal Monitor chest pain, rhythm, vital signs Monitor puncture site for bleeding o External, Internal (hematoma) Monitor extremity circulation – pulse, colour, sensation (Q15min, then decreasing frequency)
Monitor enzymes, hbg/hct, platelets, coagulation status Hydration
Hemostasis Approaches
Vascular closure device Mechanical homeostasis
Pharmacologic Adjuncts to PCI
Anti-platelet and anticoagulant therapy (pre, during, post-procedure) o To reduce risk of coronary thromobosis o Pressure applied to atherosclerotic lesion → exposes highly thrombogenic material → substantial risk of clotting → coronary artery obstruction. o Stents are thrombogenic protheses Drug eluting stents have significantly reduce incidence of re-stenosis Anti-platelet agents o Aspirin – pre-op & indefinitely after discharge o P2Y 12 inhibitors (e., clopidogrel[Plavix]; Ticagrelor (Brilinta) – pre-op and for 12 months (individualized) Anticoagulants o Heparin o Low molecular weight heparin (enoxaparin)
Complications of PCI
Coronary artery dissection (due to vessel injury secondary to balloon inflation) Coronary artery perforation/rupture (< 1%) Abrupt vessel closure (< 1%) Coronary vasospasm Restenosis (< 10% with DESs) Stent thrombosis (prevent with dual anti-platelet rx) Bleeding o at site o elsewhere [r/t anti-coagulants/anti-platelets]) Contrast-induced renal failure AMI: 5-15% (2 – 5% if stented Death (<1%) Stroke Pseudoaneurysm -
Comparison of Treatment Types
Stable angina o Medical treatment recommended over PCI or CABG (DES may change this) o PCI (or CABG) for more severe symptoms refractory to medical therapy Unstable angina and NSTEMI o Improved outcomes with early (within 24 hr) PCI PCI vs thrombolytics for STEMI o Improved outcomes with PCI versus thrombolytics (FMC to device time of 90 minutes recommended) o Fibrinolytic therapy – also time dependent (6-12 hr). FMC to device time 30 min recommended o Guideline: Transfer to PCI capable hospital with goal of balloon within 120 minutes of first medical contact o As the time delay in performing PCI increases, mortality benefit of PCI over fibrinolysis decreases.
Surgical Revascularization
Renal
Off-Pump CABG (OPCABG)
CABG without cardio-pulmonary bypass Also called “beating heart” CABG Chest is opened as per “on-pump” CABG Mechanical heart stabilizer restricts movement Any coronary artery – but difficult to do distal anastomosis on a beating heart
MIDCAB Procedure
Minimally Invasive Direct Coronary Artery Bypass Small incision L side chest (provides less access to coronary arteries) o For 1 – 2 vessels on anterior surface (e. LAD) Stabilizer for operative area
Robot Assisted Coronary Artery Bypass (RACAB)
Robotic device used to perform surgery without separating the sternum. Surgeon does not have direct contact with the patient; performs the operation via “joysticks” while watching a video screen.
Hybrid Revascularization Procedure
Combines OPCAB with PCI o Internal Mammary Artery is best choice for anterior heart o Can be done at same time in same room or different days/rooms
Comparison of Treatment Types
OPCAB (off pump) vs on-pump CABG o Similar mortality, stroke, MI, renal failure, neuro function o More repeat revascularization with OPCAB o OPCAB Less blood loss and transfusions Less morbidity, shorter LOS BUT – fewer grafts tend to be done with OPCAB PCI versus CABG o Higher incidence of stroke after CABG o CABG generally recommended for multi-vessel, complex lesions, o PCI recommended for single (sometimes left main) vessels o Freedom from angina better after CABG o Less repeat revascularization procedures with CABG o PCI less costly initially, but over time only 5% less cost
Patient Teaching Post CABG
Avoid heavy lifting (> 10 lb) x 3 months) Avoid strenuous arm movement. No weight-bearing with arms (e., use legs to get out chair) No driving x 6 wk Avoid side-lying and prone positioning x 3-4 months Resume sexual activity when can climb 2 flights stairs without stopping Daily inspection and cleansing of incisions (soap/water) Medications, diet, cardiac rehab, smoking, flu vaccine
Pain management
Coronary Revascularization
Course: Nursing Care- Complex Health Problems II (11-63-375)
University: University of Windsor
