Percutaneous Transluminal Coronary Angioplasty

Cardiovascular disease is one of the primary causes of death in industrialised countries and is one of the leading causes of death World wide. Coronary artery disease (CAD) is among the leading causes of heart Disease and stroke, accounting for 60% to 70% of myocardial infarctions (MIs) and 50% to 80% of deaths from heart disease in Western countries. In the United States alone, more than 500,000 procedures for coronary angioplasty are performed each year. Percutaneous transluminal coronary angioplasty (PTCA) has emerged as a highly effective alternative to bypass surgery to treat a wide range of arterial stenoses (narrowing), particularly those resulting from CAD.

Percutaneous Transluminal Coronary Angioplasty Protocols

Hardware’s Needed

• 7F sheath
• Puncture needle (18G)
• Introducer needle
• Y – Connector
• 10 cm extension – 1
• Torque – 1
• Inflation device
• Extra sponges
• I.V set – 2
• 10ml luerlock syringe -2
• 10ml BD syringe -2
• 5ml BD syringe -1
• 5ml Luerlock syringe – 1

Sterile Materials

Right Coronary Artery or Left Coronary Artery Guiding catheter

0.035 x 145cm Teflon guide wire

Guiding catheter (EBU, JR, JL)

0.018’’PTCA guide wire

PTCA balloon (Sprinter, Trek, etc..) and Stent (drug eluting and non-drug eluting stent)

Preparation

• Both sides of the groin to be painted with Beta-Din solution and Drape the patient with Angiogram kit.                                

• Keep things ready Air free for puncture

• Prepare manifolder ready for use: how to do?

• Now attach the 10cm extension with manifolder and connect Y connector in front

• Now open the 2nd port of manifolder to flush out the whole system at the same time close the center port of the Y connector with one finger and open the side port valve fully and close tightly. Close the 2nd port and open the pressure line and take 5 ml saline from the 2nd port in 10cc syringe and close that and keep it ready to flush the catheter.

• Prepare the inflation device with contrast
  • Take 10ml contrast in the bowl and dilute it in 1: 3 ratio (means 10 cc contrast in 30 ml of saline)

• Aspirate the contrast into the inflation device up to 10cc and De air it by tapping it and expelling the air out.

• Take that diluted contrast in 10cc Luerlock syringe (up to 5cc) and attach the long needle keep it ready to prepare the balloon

• Take 5 ml of 100mg NTG in a 10cc BD syringe and from that take 1cc in 5cc Luerlock syringe and dilute that into 3cc and keep it ready to give Intra Coronary injection.

• Take 5 – 10 gauze and dip in basin saline and keep it ready to wipe the PTCA wire frequently

Percutaneous transluminal coronary Angioplasty Procedure Steps

• Once arterial puncture is made sheath is to be introduced

• Flush the sheath and injection. Heparin 10,000IU to be given

• Prepare the guiding catheter and wire

• Introduce the wire 0.035’Teflon along with catheter & remove the wire, attach the manifolder Y connector and open the Y connector valve to let the blood come out through that and close the value. Then aspirate the blood and again flush into the value do the same twice

• Once the catheter hooks the coronary check to be given to confirm the flow

• Two or three views to be taken and PTCA wire to be introduced along with introducer through Y- connector value

• Remove the wire introducer & close the value

• Put the torque device on the wire & Be ready for check angiogram

• Once the wire crossed over the lesion, one proper coronary shot to be taken

• Then lesion size to be measured. Pre-dilatation or direct stenting can be done

• If pre dilatation is required, Balloon is prepared by following these steps

• Attach the inflation device with the balloon and put it in negative pressure

• Wipe the PTCA wire with wet gauze and thread the balloon over the wire

• Y connector valve to be open and introduce the balloon into the catheter then it should be closed

• Be ready to give check contrast when the balloon is crossing the lesion

• Once the balloon has positioned on the lesion check angiogram to be taken

• Then put the Inflation device in positive pressure and inflate the balloon up to its nominal pressure.

• Wait for 30 sec and during that time ECG, B/P & saturation to be noticed.

• Deflate slowly and put inflation device in negative pressure

• Again check angiogram to be done to note the lesion severity

• Remove the balloon slowly by keeping the wire in position

• Wipe the wire with wet gauze. Appropriate stent size to be selected

• Take out the stent from the cover and remove the stylet and flush

• Fill up the hub of the stent with diluted contrast and connect the inflation device in positive pressure. (Do not put the inflation device in negative pressure for stent)

• Put the stent over the wire and introduce it into the catheter through Y-Connecter valve

• Close the valve and push the stent into the lesion, position the stent properly.

• Implant the stent by inflating with inflation device up to its nominal pressure or more than that

• Wait for some time and deflate it slowly then remove the stent catheter

• Check angiogram to be performed, if post dilatation is required it can also be done by same method of pre-dilatation

• Remove the wire and again check angiogram is performed in different views

• Remove guiding catheter with 0.035 Teflon guide wire then send sample for ACT

• Flush the sheath and suture it with Appropriate suture materials

• Apply pressure bandage and shift the patient to CCU

Post Procedure Management

Now with the wider acceptance of femoral puncture site closure devices and radial access, it is popular to remove the arterial sheath in the catheterization laboratory at the end of the interventional procedure , despite a fully anti-coagulated state. After sheath removal, the patient usually remains at bed rest for 6 hours and then ambulates before discharge. The time to ambulation is significantly reduced, however, if a femoral closure device was used. If a glycoprotein lIb/IlIa receptor antagonist is used intra-procedurally, it is commonly infused for approximately 18 hours post procedure, though there is a tendency toward shorter infusions in order to reduce the risk of bleeding