What is it and why is it done?
Stenting of the coronary vessels is one of the most effective and minimally invasive methods of treating coronary artery disease by installing a metal mesh on the narrowed segment of the coronary artery.
Percutaneous coronary intervention (PCI) is done in patients with critical narrowing of the lumen of the myocardial arteries. Stenting of cardiac vessels has become widespread due to the fact that:
- the technique for performing the procedure is relatively simple;
- the operation is practically bloodless (unlike CABG);
- does not require much time (compared to coronary artery bypass grafting);
- the operation does not require general anesthesia;
- few complications;
- the recovery period is shortened as much as possible.
Indications
Coronary stenting is prescribed:
- In acute myocardial infarction (AMI) without ST segment elevation.
- In the first 12 hours from the development of symptoms in AMI with ST elevation.
- With angina pectoris III-IV FC against the background of correctly selected drug therapy.
- Unstable angina pectoris:
- first appeared;
- progressive;
- early and late postinfarction.
- Recurrence of angina pectoris after previously performed myocardial revascularization.
- Painless myocardial ischemia.
There are no absolute contraindications for surgery today (with the exception of the patient's refusal).
Relative contraindications:
- the diameter of the artery is less than 2 mm;
- severe coagulation disorders;
- end-stage renal failure;
- diffuse stenosis of the coronary vessels;
- an allergy to iodine (a component of an X-ray contrast agent).
Heart attack and stenting
Intervention for acute coronary syndrome is indicated in such cases:
- the first hours of a heart attack;
- with the development of episodes of angina pectoris within a week after a heart attack;
- angina pectoris during exercise and at rest;
- asymptomatic variant of ischemic disease;
- narrowing of the lumen of the cardiac artery by more than 50%, according to the conclusion of ultrasound;
- re-stenosis after previously performed stenting.
Types of stents
A stent is a high-tech structure, which is a tubular frame made of a medical alloy (cobalt, steel, chromium, tantalum, platinum and nithiol), absorbable materials or polymers with improved biocompatibility, which, being located in the lumen of a narrowed vessel, expand it and renew blood flow on it.
There are about 400 types of stents, differing in manufacturer, composition, mesh, coating and placement system.
Types of stent designs:
- Expandable balloon:
- tubular;
- spiral;
- wire;
- sinusoidal (annular).
- Self-expanding (mesh).
The cells are divided into closed, open, with reservoirs, beams of various thicknesses, lintels.
Stent shapes:
- cylindrical;
- conical;
- bifurcation;
- ultra low profile (for narrow vessels).
Varieties of stents by type of coverage:
- "Passive":
- carbon;
- titanium oxynitride;
- "Artificial endothelium".
- Mechanical:
- stent grafts;
- with microgrid.
- Medicinal:
- limus;
- paclitaxel;
- others (Tacrolimus, Trapidil, Dexamethasone, Heparin).
- Hybrid (combination of active and passive).
Hybrid stents have a polymer coating that releases a substance that resists endothelial fouling of the structure. The second layer encapsulates the stent, preventing metal particles from entering the tissue.
The latest models have asymmetric drug coverage, which prevents it from entering the systemic circulation.
A new development in cardiology - US-made biodegradable stents, which provide temporary mechanical support for opening the coronary artery, followed by resorption for 24 months. This group is intended for implantation in patients of young age or with uncalcified plaque.
How does the installation work?
The full name of the procedure is percutaneous transluminal balloon angioplasty (PTA).
Before the intervention, the patient must undergo coronary angiography (X-ray contrasting of the myocardial vessels), according to the results of which the vulnerability of the plaque is determined, a decision is made on the advisability of installing a stent, and its type, diameter and size are selected.
Additionally, the fractional reserve of the coronary circulation (FFR) is measured - the ability of this vessel to provide the heart with sufficient blood. Sometimes an MRI is required.
ChTBA stages:
- Under local anesthesia, a large artery (femoral, radial, brachial, ulnar) is punctured. The most common is the femoral approach. Below the inguinal fold, a skin incision is made, the vessel is punctured with a needle, a guidewire is inserted, and an introducer designed for the introduction of instruments is installed.
- The mouth of the coronary artery is catheterized, a special guide is inserted below the narrowing of the vessel, through which the necessary instrument will be delivered to the site of the lesion.
- A balloon-catheter is delivered via a guidewire to the lesion, preliminary expansion of the area with an atherosclerotic plaque is performed.
- The balloon-catheter is replaced with a balloon with a stent and is brought to the site of insertion under X-ray control.
- The balloon with the stent is inflated under a pressure of 10-14 atm.
- The balloon is deflated and slowly removed from the artery.
- A control coronary angiography is done to make sure that the stent is correctly placed inside the vessel.
- The introducer is removed, a suture and an aseptic bandage are applied to the incision area.
After the procedure, you need to adhere to bed rest for 24 hours. The condition of the puncture site is carefully monitored throughout the day. After this period, the bandage is removed, and for another two days the patient is allowed to move only around the department.
Stent installation video:
Cost of procedure and device
Stenting is quite an expensive undertaking. The price of a stent can vary from $ 800 to one and a half thousand, depending on the type of guidewire (the presence of a drug coating, the frequency of retrombosis, the type of alloy). The installation cost is usually 5-10% of this amount. Moreover, there are government programs and quotas that allow a patient to get a stent for little money in the first hours of acute coronary syndrome. There are also benefits for elective surgery - patients who need the procedure according to coronary angiography data have the opportunity to qualify for a substantial discount on a first-come, first-served basis.
Complications
The number of complications from the procedure decreases every year. This is due to improvements in tools, new drug support regimens, and the accumulation of expertise by physicians.
Possible complications:
- Cardiac (often develops during CTBA):
- spasm of the coronary artery (CA);
- dissection of the coronary artery (ruptures of the inner and / or muscular membrane of the artery);
- acute occlusion of the vessel;
- the phenomenon of non-renewal of blood flow;
- perforation of the operated vessel.
- Extracardiac:
- transient violation of cerebral blood flow;
- allergy to contrast agent;
- hematoma, infection, thrombotic occlusion, bleeding at the puncture site;
- ischemia of the lower extremities;
- retroperitoneal bleeding;
- contrast-induced nephropathy;
- lactic acidosis;
- microembolism.
In the postoperative period, rhythm disturbances, heart failure are possible, in 1.1% of cases - thrombocytopenia, bleeding.
Rehabilitation and drugs: what and for how long to drink?
The patient is discharged on the sixth to seventh days under the supervision of the attending physician.
Recovery rules:
- after surgery on the heart, for 3 days, the patient should be in the intensive care unit under the supervision of doctors;
- control over the condition should be carried out using a special cardiac monitor;
- it is necessary to conduct an electrocardiogram in dynamics (heartbeat check), ECHO-KG, examination of the wound in the puncture zone of the femoral artery;
- laboratory tests are shown to control markers of inflammation, coagulogram, blood coagulation;
- postoperative soft catheter from the femoral artery is removed within 24 hours, after which a bandage is applied;
- 24 hours after the placement of the coronary stent, no active leg movements should be performed;
- on the second day, it is allowed to bend the hip and gently move around the room;
- within two days it is necessary to drink at least 1-2 liters of water for excretion; x-rays of the contrast agent from the body;
- you can eat right after the procedure;
- 7 days after the intervention, physical activity is strictly limited;
- the first 3 days it is not recommended to walk more than 50 - 100 m;
- by the end of the first week, it is allowed to slowly walk up to 200m;
- discharge from the hospital is carried out in the absence of complications and is indicated for 3-5 days;
- the first 6 months after the operation, excessive physical activity, sports are prohibited; you should limit your sex life for up to six months;
- hypothermia should be avoided; in case of diseases of the upper respiratory tract, oral cavity, tonsillitis, dental caries - consult a doctor for treatment.
In order to prevent thrombotic complications, the patient is prescribed double antiplatelet therapy, which consists of:
- "Acetylsalicylic acid" (loading dose - 150-300 mg / day, maintenance dose - 75-100 mg throughout the year);
- "Clopidogrel" at a loading dose of 600 mg / day, and then a maintenance dose of 75 mg. An alternative is Tricagelor (180 mg / day).
Patients with a high risk of thrombotic complications in the first two months are shown the additional appointment of "Warfarin" under the control of APTT.
The need to prolong antiplatelet therapy is considered individually.
What is the cause of chest pain after the intervention and what to do?
In 95% of cases, endovascular interventions and stent placement on the coronary arteries of the heart are successful. The main reasons for the deterioration of the condition after the intervention:
- wrong choice of stent;
- violation of the installation method;
- progression of the underlying process and disease;
- premature destruction of the stent.
The most serious and dangerous complication is thrombosis of the narrowed artery in the first hours after surgery. This is evidenced by the fact that after stenting there may be pain in the chest.
The main causes of pain after coronary stenting are:
- After stent placement, blood flow resumes. Changes in hemodynamics can cause discomfort and discomfort in the chest for the first 2-4 weeks after surgery.
- Small damage to the vessel anywhere in it can lead to bruising a few days after the intervention.
- The increased blood flow can provoke detachment of the inner lining of the vessel, its tear, the development of postoperative aneurysm of the stented artery.
- The displacement of the stent in the vessel and its movement with the blood flow can cause pain due to the violation of normal hemodynamics.
- Re-narrowing the area of the stent with a blood clot further disrupts blood flow to the heart muscle. The most dangerous postoperative thrombosis of the coronary arteries.
- Disruption of sinus rhythm and the appearance of arrhythmias due to increased blood flow to the heart area and activation of another focus of the pacemaker.
Life after stenting and feedback on the procedure
A month after discharge from the hospital, the patient undergoes outpatient stress tests with cardiogram registration. The degree of physical activity permitted depends on the results of the study.
After leaving the hospital, the person continues to recover in the sanatorium. Rehabilitation after stenting of the heart vessels is aimed at expanding physical activity, selecting individual exercises that are performed independently at home, and modifying the lifestyle. Reviews of the procedure are extremely positive - most patients quickly return to their normal rhythm of life and become able to perform all routine activities.
Quality and durability
The postoperative prognosis is generally favorable. An increased mortality rate after PTBA is observed only during the first 30 days. The main reasons are cardiogenic shock and ischemic brain damage. At the end of the month, the mortality rate does not exceed 1.5%.
Coronary artery stenting is not a basis for determining disability. But it can be appropriated due to the disability that caused the disease, which became the indication for surgery.
Undoubtedly, CTBA improves the patient's quality of life. But its duration depends on the secondary prevention of cardiovascular diseases, regular medication and adherence to the doctor's recommendations.
Physical exercise
Dosed physical activity maintains the tone of the circulatory system and improves the future prognosis of the patient's life.
Walking, cycling, exercise therapy, swimming slow down the progression of atherosclerosis, help lower blood pressure and normalize weight.
It is worth remembering that only dynamic loads and aerobic exercise are recommended.
Leisure and travel
After successful rehabilitation, with the permission of the attending physician, a person can freely travel to any distance without any consequences, provided that the recommendations are followed and the medication is taken.
Sauna is not recommended.
How long do you live after surgery?
Life expectancy after PTBA mainly depends on the pathology that became the indication for surgery, concomitant diseases, left ventricular ejection fraction, and the patient's age.
The five-year survival rate after CTBA is approximately 86%.
Alcohol
Alcohol does not directly affect the functioning of the stent. But its use in conjunction with antiplatelet therapy is prohibited. Also, alcoholic beverages are not recommended for all people with cardiovascular diseases.
Diet and diet after stenting
After the operation, you need to follow a lifelong diet low in animal fats, fast carbohydrates, salty, fried and pickled foods, stop smoking, and reduce caffeine intake. Five to six small meals are recommended.
Conclusions
Coronary stenting eliminates the consequences of atherosclerotic lesions of the heart vessels, blockage and stenosis of the arteries. This procedure does not completely eliminate ischemic disease, the main causes of which are metabolic disorders, metabolic diseases, smoking, alcohol abuse, progressive atherosclerosis. After stenting, every patient should be aware of the need to follow the doctor's recommendations and not break the medication schedule. In case of discontinuation of therapy and non-compliance with preventive measures, the risk of sudden thrombosis and blockage of the stent in the artery of the heart increases several times.
A prerequisite for observing a patient is dispensary registration, regular preventive examination by a cardiologist or therapist.This allows you to identify the slightest signs of a developing relapse and, as soon as possible, take measures to eliminate stenosis of the coronary vessels, refer the patient to a cardiac surgeon and re-stent.
