8/2/2019 angio endo

1/24

SHRI G.S. INSTITUTE OF

TECHNOLOGY & SCIENCE

(AN AUTONOMOUS

INSTITUTION ESTABLISHED IN 1952)

DEPARTMENT OF BIO MEDICAL ENGINEERING

REPORT

ENDOSCOPY AND

ANGIOPLASTY

8/2/2019 angio endo

2/24

SUBMITTED TO:-

SUBMITTED BY:-

Mrs. VIBHA BHATNAGAR

AB~39001 ADITYA GUPTA

AB~39004 ASHISH ADWANI

Foreign Body Extraction

General

A variety of foreign bodies may accidentally or intentionally enter the gastrointestinal

(GI) tract. In about 90% of cases, however, they spontaneously pass out through the

GI tract. The remaining 10% comprise sharp, pointed, or bulky objects, which can

cause local trauma or chemical damage to the mucosa. Nearly all such foreign bodiescan be extracted with a flexible endoscope.

Indications

An emergency indication for endoscopic extraction is an impacted foreign object.

Acute obstruction of the esophageal lumen can cause aspiration pneumonitis or

pressure on the esophageal wall resulting in perforation and mediastinitis. Foreign

objects can become impacted in the esophagus at the three physiologic levels of

narrowing: the cricopharyngeal sphincter, aortic arch, and diaphragmatic hiatus.Objects that reach the stomach and are likely to pose a risk of mechanical or toxic

8/2/2019 angio endo

3/24

injury should also be removed without delay. In addition, objects that remain in the

stomach for more than 72 hours should undergo early endoscopic extraction since

their spontaneous passage is unlikely. A bezoar requires debulking by endoscopic

fragmentation to facilitate its removal.

Prerequisites

Prior to endoscopic extraction of a foreign body, information regarding the type,

form, and size of the foreign body is required to plan the strategy of removal and to

select the instruments to be used. A plain radiograph of the upper GI tract may not

always adequately localize the foreign body, and therefore a contrast study may be

necessary. If a perforation is suspected, a water-soluble contrast agent like

Gastrografin is preferred.

The colon may also require evaluation with a contrast enema study. If an esophageal

foreign body is suspected, then a plain radiograph of the chest should also include theneck as it is not unusual for foreign bodies to impact at the cricopharyngeal sphincter.

Children and uncooperative adults often require general endotracheal anesthesia so

that the procedure can be carried out safely and successfully.

Figs. 16)

Fig. 1a, b Extraction of a coin from the esophagus. a In children, a coin often impactsat the level of the cricopharyngeal sphincter.

8/2/2019 angio endo

4/24

b A coin with an elevated edge is easy to grasp and extract with the rat-tooth forceps.

Coins with a smooth edge can be grasped with rubber-coated prongs.

Instruments

Apart from pediatric and therapeutic upper endoscopes, the endoscopic

armamentarium should include a variety of forceps (crocodile, rat-tooth, etc.), snares,

Dormia baskets, and a long overtube.

Technique

An overtube is recommended when removing pointed or sharp objects to avoid

damage to the esophagus and pharynx. Small or slippery objects should also be

removed through an overtube. It is safest to insert the overtube over a guidewire,

using an appropriately sized bougie (generally 45-French) as an obturator. If the

foreign body occludes the lumen completely and prevents guidewire placement, then

the overtube can be preloaded over the endoscope and pushed into place after the

endoscope has been inserted across the pharynx. In such a case, a therapeutic

gastroscope should be used to reduce the step formation between the endoscope and

the overtube.

Complications

Perforation is the most serious complication that can result from endoscopic foreign

body extraction. This usually occurs when removal is difficult or requires excessive

force. As

8/2/2019 angio endo

5/24

a rule, objects obstructing the esophageal lumen should not be pushed into the

stomach. Sharp or pointed objects that can lacerate the mucosa should always be

removed through

an overtube. Injury to the GI wall, whether due to pressure necrosis, a tear, or a

difficult extraction, should be promptly investigated with a radiographic contrast

study using a watersoluble contrast agent to rule out a perforation. The possibility of adelayed perforation caused by tissue necrosis should also be kept in mind. Dietary

restrictions and acidsuppressive or mucosa-protective drug therapy may be indicated,

and the patient (or responsible next of kin) should be informed about the risk of

delayed perforation. The risk of a foreign body aspiration during extraction also

deserves emphasis. Apart from using an overtube, endotracheal intubation is

recommended for patients at increased risk for aspiration. This also includes the

patient who is not fasting and particularly if intravenous sedatives are administered

prior to the endoscopic procedure.

Bougienage and Balloon Dilation

General

Bougienage or pneumatic dilation is commonly performed for the treatment of benign

and malignant strictures of the esophagus, and occasionally for pyloric or colonic

strictures. Biliary and pancreatic duct strictures are also amenable to dilation.

Repeated dilation is usually necessary to achieve a satisfactory long-term therapeuticresult.

Indications

The main indication is a benign, fibrotic stricture of the esophagus. The etiology is

usually peptic (recurrent reflux esophagitis) or postoperative (anastomotic stricture).

Bougienage is also often indicated prior to stent placement for malignant strictures ofthe esophagus or bile duct. Benign strictures of the bile duct (postoperative, sclerosing

cholangitis) and pancreatic duct (chronic pancreatitis, posttraumatic) are candidates

for bougienage or pneumatic dilation if the stricture is short (see Chapter 11, Biliary

Stent Drainage, and Chapter 12, Pancreatic Duct Stenting and Stone Extraction).

Stenoses in other locations (pylorus, rectum, colon, or gastrointestinal [GI] and

biliodigestive anastomoses) are less common indications that require a further workup

before general recommendations can be made. The role of endoscopic dilation for

strictures of chronic inflammatory diseases such as Crohns disease and diverticulitis

needs to be assessed on a patient-to-patient basis, taking into account the endoscopic

and radiographic findings and the riskbenefit ratio as compared with surgical

options. Pneumatic dilation is an alternative to surgical cardiomyotomy for thetreatment of achalasia. Repeated dilations are usually required. Intramural injection of

8/2/2019 angio endo

6/24

botulinum toxin is an endoscopic alternative that may achieve results similar to those

of pneumatic dilation.

Prerequisites

A preliminary radiographic contrast study is recommended to provide an anatomic

road map. A small-diameter gastroscope is used for the initial evaluation. Biopsies

are

obtained to determine the nature of the stricture. Since a negative biopsy does not rule

out malignancy, repeat biopsies may be required after dilation before a stricture can

be labeled as benign. The majority of benign strictures require repeated sessions of

dilation over a prolonged period of time. Patient education and compliance are

therefore important requirements of endoscopic therapy. Patient compliance can be

enhanced by minimizing the level of procedural discomfort. Most dilation procedurescan be performed under intravenous sedation on an outpatient basis. Procedures are

initially repeated at 3- to 4-day intervals and then at 2- to 3- week intervals.

Perforation is the most common and dangerous complication that can follow

bougienage or pneumatic dilation. Appropriate patient selection, correct choice of

instruments, and a cautious technique are the key factors in avoiding perforation.

Fig. 20 Dilation over a hydrophilic guidewire is possible with small-diameter bougies

(up to 30-French). The stricture should be inspected after dilation with a small-

diameter endoscope to rule out deeper tears.

8/2/2019 angio endo

7/24

Fig. 21a, b The hydrophilic guidewire, which is not as stiff as the metal guidewire, is

not suited for bougienage of tight or infiltrating strictures. a A radiopaque 9-French

catheter is inserted over the hydrophilic guidewire, through which the hydrophilic

wire is exchanged for the more rigid Eder-Puestow wire.

Instruments

The most widely used bougies for esophageal dilation are the flexible Savary-Gilliard

bougies made of PVC (polyvinyl chloride). These come in diameters ranging from5 to

20 mm. Bougies made of stiffer plastic material may occasionally be required for

extremely tight or infiltrating strictures. The diathermic needle knife, the argon

plasma-coagulator,

or the Nd:YAG laser can be used to incise fibrotic ring strictures. TTC (through-the-channel) balloon dilators can be inserted through the biopsy channel of the endoscope

and are available in diameters ranging from 6 to 25 mm. Larger balloon dilators with

diameters of 30, 35, and 40 mm, which are used for the treatment of achalasia, are

inserted over a guidewire. An alternative to the balloon dilator is a balloon that is

attached to the end of the endoscope. In contrast to balloon dilators, which are made

of low-compliance plastic polymers, the balloon attached to the endoscope is made of

latex rubber and consists of three layers. Biliary and pancreatic duct strictures can be

dilated with Teflon dilators or hydrostatic balloons . Bougienage of strictures initially

entails the placement of a Savary-Gilliard guidewire across the stricture through the

biopsy channel of the endoscope. The wire is available with or without calibrations,

the former wire being mandatory if dilation is performed without fluoroscopy.Hydrophilic guidewires commonly used for the biliary and pancreatic ducts (260 cm

8/2/2019 angio endo

8/24

long, 0.035 or 0.038 in, J-shaped tip) are also used for negotiating long, tight, and

tortuous strictures.A pediatric endoscope (outer diameter of 5.3 or 7.9 mm) may be

necessary to pass a tight or difficult stricture.

Technique

Bougienage should always be performed over a guidewire. Therefore, proper

placement of the guidewire is the key to a successful and safe procedure. Balloon

dilation with smaller TTC balloons are performed under direct endoscopic guidance.

The choice of the balloon or size of the dilator depends upon the tightness of the

stricture. This can be judged by the radiologic and endoscopic appearance of the

stricture and the resistance encountered during passage through the stricture.

Esophageal Stent

Placement

General

Esophageal stenting palliates obstructive symptoms caused by tumors of the

esophagus and the cardia. Stent placement not only relieves dysphagia, thus enabling

oral nutrition, but also prevents aspiration pneumonitis. Tracheoesophageal fistulae,

too, can cause similar complications. The major advantage of stent placement over

other palliative treatments is the prompt relief of dysphagia.

Indications

The primary indications are dysphagia and tracheoesophageal fistulae due to

advanced, unresectable, or inoper-able tumors of the esophagus and cardia. Less

scommon indications are strictures at other sites, such as the distal stomach or rectum,

that fulfill criteria in which palliative surgery is either not feasible or too hazardous.

Prerequisites

Fundamental prerequisites for stent placement are confirmation of malignancy on

biopsy and unresectability on imaging studies. The palliative objectives should be

well defined

and the symptoms should correspond to findings on radiologic and endoscopic

imaging (including endosonography and bronchoscopy). Despite the larger diameter

of self-expandable metal stents, palliation of dysphagia may not be superior.

Peristalsis

an important component of swallowingis impaired by the tumor as well as the stent.

Thus, a larger stent diameter may not necessarily enhance the patients ability toswallow.

8/2/2019 angio endo

9/24

A reasonable goal of treatment is the ability to swallow a soft pureed diet, for which

an inner stent diameter of 10mm usually suffices. In the literature plastic stent

placement has been complicated by high perforation rates, partly due to the need for

extensive bougienage prior to stenting. Selecting a plastic stent with a smaller

diameter (10 mm), soft material, and proper technique (see following text, Technique)

will minimize the risk of perforation. Plastic and expandable stent placement requirespreliminary dilation of the tumor stenosis. To avoid perforation, bougienage should be

performed gradually and, if necessary, in several sittings. Excessive dilation should be

avoided to prevent subsequent migration of the stent.

Fig. 34 Instruments for plastic stent placement: bougie with the Savary-Gilliard

guidewire, transparent pusher tube with markings in centimeters, and a plastic stent.

Instruments

A variety of plastic (silicon, latex, Tygon) and self-expanding metal (stainless steel,

nitinol) stents are available for the treatment of tumors obstructing the esophagus

and/or cardia . Self-expandable stents are covered to prevent tumor ingrowth. The

expandable stents differ in their expansile force, flexibility, release mechanisms,

radiographic visibility, and retrievability. Expandable stents equipped with anti-reflux

mechanisms (valve, windsock) have been designed for low esophageal or cardia

strictures. Plastic stents may need to be modified to accommodate special anatomic

situations. For cervical esophageal strictures a stent with a short funnel and a small

diameter (outer diameter of less than 10 mm) is used to avoid or minimize foreign

body sensation and tracheal compression. For distal esophageal or cardia strictures a

stent with distal flaps to prevent proximal migration is used (Fig. 33). To seal off a

fistula, a stent with a wide funnel is used (this can be achieved by adding a second

funnel). Silicone flaps and a second funnel are added to the stent with a fast-acting

glue. Fluoroscopy is required to guide expandable stent placement, but is not

mandatory for the insertion of a plastic stent. A 29-French bougie serves as an

introducer for a stent with an internal diameter of 10 mm, inserted over a Savary-

8/2/2019 angio endo

10/24

Gilliard guidewire. The stent is advanced with a 14- mm calibrated pusher tube (Fig.

34).

Percutaneous EndoscopicGastrostomy (PEG)

General

Percutaneous endoscopic gastrostomy (PEG) is the intentional formation of a

gastrocutaneous fistula for the purpose of enteral feeding. It has gained widespread

popularity because it is technically easy, rapid, and safe. It is preferable to nasoenteral

feeding tubes for long-term enteral feeding.

Indications

PEG is primarily indicated in patients who are unable to swallow. The causes are

usually neurogenic impairment or obstructive tumors of the oral cavity. Less

commonly, PEG

may be indicated for nutritional support of the undernourished patient with gross

anorexia.

Prerequisites

Percutaneous transgastric nutrition requires a patent bowel. This can usually be

determined from the patients history. Gastric outlet obstruction should be ruled out

on an upper gastrointestinal (GI) endoscopy. Residual food or secretions

in the stomach or duodenum in the fasting patient signal the possibility of outletobstruction. Stenoses in the oropharynx and esophagus may require a preliminary

bougienage. An absolute prerequisite for PEG is a close contact between the anterior

wall of the stomach and the abdominal wall. Interposed viscera are excluded by

transillumination through the abdominal wall with the endoscope. Hepatomegaly can

also impede PEG and is excluded by physical examinationPortal hypertension

increases the risk of bleeding during PEG and should consequently bewatched out for

and tested for. Preoperative broad spectrum antibiotics are generally recommended as

a prophylaxis against infection. The abdomen is prepared and draped as for an

abdominal operation. The key to avoiding complications is proper postoperative

careespecially during the firstweekuntil the parietal and visceral peritoneum have

fully adhered. Tube feeding can be started on the same day as placement if the tube isproperly positioned and anchored.

8/2/2019 angio endo

11/24

Fig. 42 Assuming normal GI anatomy, the puncture site is approximately 23

fingerbreaths under the left costal margin in the paramedian line. In the patient with a

Billroth II operation, the puncture site is along the left costal margin.

Instruments

Gastrostomy sets differ according to the technique used. The pull technique is the

most commonly used. In general, a 15- French feeding tube is adequate for instilling

commercially available enteral nutrition preparations. Most PEG tubes have an

internal bolster measuring approximately 2.5 cm in diameter and can be fixed to the

abdominal wall by an adjustable external bolster. Antiseptic solution, scalpel, gauze

dressing, and various adaptors for the feeding tubes are usually supplied in most

commercially available kits. A special 110-cm-long 9-French tube is also available for

placement in the jejunum (percutaneous endoscopic jejunostomy). PEG is performed

using a standard diagnostic gastroscope with a 2.8-mm working channel. The thread

can be grasped with a biopsy forceps or polypectomy snare. A rattooth forceps is

necessary for placing a jejunal feeding tube.

Technique

In the more popular pull technique, the PEG tube is pulled through the oropharynx

with the aid of an attached thread that pulls it out through the stomach and abdominal

wall.

Using the push technique, the tube is percutaneously inserted directly into the

stomach over a guidewire. Although the push technique is a more direct approach, it

requires serial dilation of the puncture tract to allow insertion of the PEG tube and is

thus more complicated and involves more risk than the pull technique. The procedure

begins with a standard esophagogastroduodenoscopy in the left lateral position.

Stomach contents are cleared with endoscopic suction.

8/2/2019 angio endo

12/24

Enteral Tube Placement

General

Tubes are endoscopically placed into the jejunum either to enable enteral feeding or todecompress the small bowel. A tube can also be inserted into the colon to decompress

it.

Indications

A jejunal tube is indicated for enteral feeding when gastric emptying is impaired

because of mechanical obstruction or a motility disorder. Long-term jejunal feeding

warrants a percutaneous endoscopic gastrostomy (PEG) through which the feeding

tube is inserted. A jejunal tube is also indicated for small-bowel decompression in

patients with unclear intestinal obstruction (e.g., ileus in the early postoperative

phase). Tube decompression

of the colon is indicated for colonic pseudo-obstruction.

Prerequisites

Bowel decompression should not be an excuse for postponing a necessary operation.

This applies particularly to mechanical intestinal obstruction. Distal propagation of

the

Dennis tube requires at least some peristaltic activity. In the setting of a complete

adynamic ileus, a Dennis tube is no better than a nasogastric tube. Endoscopicdecompression of colonic pseudo-obstruction is indicated when the risk of surgery is

considered to be prohibitively high.

The feeding tube is advanced under direct vision into the jejunum. The wire is then withdrawn until it lies

about 5 cm beyond the endoscope. This will prevent the tube from kinking.

8/2/2019 angio endo

13/24

Instruments

A pediatric gastroscope (outer diameter 5.9mm or 7.9 mm) is used to position a

guidewire for over-the-wire insertion of an enteral tube. A therapeutic gastroscope

with a 3.7-, 4.2-, or 6-mm working channel is used for through-the-scope (TTS)

placement of enteral tubes. A variety of enteral tubes are available: Feeding tube: 250 cm long, 9-French, with adapter

Dennis tube for small-bowel decompression: 210 cm long, 16-French triple-lumen

tube with a balloon at the tip

Colonic decompression tube: 130 cm long, 24-French polyethylene tube inserted

over a 300 cm long, 7-French radiopaque Teflon delivery catheter

Accessories required are Teflon-coated stainless steel and hydrophilic guidewires

(400 cm long, 0.035 in) and a large rat-tooth forceps to grasp the Dennis tube and

advance it into the duodenum.

Technique

The TTS technique is the easiest and fastest method of placing feeding tubes. A 9-

French feeding tube, stiffened with a0.035-in Teflon-coated guidewire, can be

inserted through a gastroscope with a 3.7-mm working channel (Fig. 60). Overthe-

wire placement is performed if a large-channel gastroas

ANGIOPLASTY

What is angioplasty?

What is the benefit of having angioplasty? What causes blockages in the arteries?

Why do I need angioplasty?

What should I expect before my angioplasty?

What happens during my angioplasty?

What should I expect after the procedure?

What is angioplasty?

Angioplasty is a minimally-invasive procedure that repairs and restores blood flow

through a narrowed or blocked artery in the heart. The procedure is performed by aninterventional radiologist.

8/2/2019 angio endo

14/24

What is the benefit of having angioplasty?

Angioplasty can prevent a heart attack or stoke by opening your blocked artery,

restoring blood flow to your tissues and relieving your symptoms without the need for

surgery.

What causes blockages in my arteries?

Blockages in arteries and veins can be caused by smoking, high cholesterol levels,

diets high in saturated fats, and cardiovascular disease.

Why do I need angioplasty?

The most common reason for angioplasty is to relieve a blockage of an artery caused

by atherosclerosis, or hardening of the arteries. Atherosclerosis is a gradual process in

which cholesterol and other fatty substances in the bloodstream form a substancecalled plaque on the inside of the blood vessel walls and clog the artery. When

medications or lifestyle changes arent enough to reduce the effects of blockages in

your arteries, or if you have worsening chest pain or heart problems your doctor may

suggest angioplasty. If you have extremely hard plaque deposits, blockages, or blood

vessel spasms that dont go away, you probably are not a good candidate for

angioplasty.

What should I expect before my angioplasty?

Prior to the procedure, you may have several tests performed, such as X-rays and

blood tests. You will be asked not to eat or drink anything after midnight the nightbefore your procedure. You should tell the interventional radiologist or nurse if you

are allergic to any medications. Angioplasty usually requires an overnight hospital

stay. Make sure you arrange for transportation home.

What happens during my angioplasty?

Angioplasty is performed by a specially-trained doctor, called an interventional

radiologist.

The interventional radiologist will use an intravenous (IV) line to give you fluids andmedicines that will relax you and prevent blood clots. Next the nurse will:

Shave the area where the catheter or tube will be inserted, usually the arm or

groin.

Clean the shaved area to make it germ free.

Numb the area.

When you are comfortable, the interventional radiologist will begin the procedure.

A small incision is made in the skin to find an artery. The doctor then threads

a very thin wire through the artery up to the coronary artery that is blocked.

8/2/2019 angio endo

15/24

When the wire reaches the area of the blockage, a tube (called a catheter) with

a deflated balloon on the end is threaded into the blocked artery under X-ray

guidance.

A small amount of dye may be injected through the tube into the blood stream

to help show the blockage on X-ray. This X-ray picture of the heart is called

an angiogram. When the tube reaches the blockage, the balloon is inflated. The expanding

balloon forces the blockage to open by pushing the walls of the artery

outward, increasing blood flow to the heart muscle.

A stent usually is placed at the site to keep the artery open. Once the balloon

has been deflated and withdrawn, the stent remains in place permanently,

holding the blood vessel open and restoring blood flow to the arteries.

What should I expect after my procedure?Your catheter site will be checked for bleeding and swelling after the procedure. Your

blood pressure and heart rate will be monitored. Your physician may prescribe

medication to relax you and protect your arteries against spasm and to prevent blood

clots. Usually you will stay at the hospital overnight and return home the day after the

procedure. You typically will be able to walk within two to six hours following the

procedure and return to your normal routine by the following week.

8/2/2019 angio endo

16/24

The Facts on Angioplasty

Angioplasty is a technique for reopening narrowed or blocked arteries in theheart (coronary arteries) without major surgery. First used in 1977, it's now as

common as heart bypass surgery. It's sometimes called percutaneous transluminal

coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI).

"Angio" means relating to a blood vessel and "plasty" means repair. Angioplasty is

also used in other parts of the body, usually to treat peripheral artery disease.

8/2/2019 angio endo

17/24

Before the operation

You shouldn't eat after midnight on the night before your angioplasty. Ask your

doctor if you can drink clear liquids after this. You can usually continue to take yourmedications, but you should discuss this with your doctor. Check with your doctor if

you take blood thinners such as warfarin, as you may need to stop them 5 days before

the procedure. If you take insulin, you may have to adjust the dose.

You must also tell your doctor if you are allergic to iodine or shellfish, since

angioplasty involves injecting you with an iodine-based dye. You may have to go for

some preliminary blood tests. Your doctor may tell you to not smoke for a period of

time before or after angioplasty. For best results, you should quit smoking

permanently.

The procedure

Angioplasty is performed while you are awake, under local anesthetic. It's sometimes

uncomfortable, but not usually painful. The surgeon makes a small incision in the

groin or arm and inserts a thin tube, called a catheter, into the artery. The catheter

includes a small balloon and a small wire tube, called a stent. Once the catheter is in

place, a dye is injected and X-rays are taken, which tell the physician exactly where

the blockages are and how narrow the artery is. This is also known as an angiogram

and functions as a map for the doctor.

The doctor will then inflate the balloon, opening the stent and pushing it against theartery wall. After the procedure is complete, the cells that line the blood vessel will

grow around the stent, holding it in place. The whole procedure usually lasts 30

minutes but may last as long as several hours. Sometimes, people will have to return

to get their arteries redone because of renarrowing (restenosis) at the site of the

balloon inflation.

There are other types of angioplasty sometimes used in combination with the

balloon:

Drug-coated stents are specially-treated stents that gradually release a special

medication into the wall of the artery after they have been put into place and

inflated. They reduce the risk of needing another procedure and are used for

people who have a high risk of developing renarrowing of the artery after the

initial procedure. These stents may increase the rare risk of clotting. Studiesare ongoing to identify safety and outcomes of the use of these stents.

Directional atherectomy involves using a miniature rotating blade to cut out

the fatty deposit and remove it from the body.

In rotational atherectomy, a diamond-studded drill bit is used to pulverize

tough blockages.

8/2/2019 angio endo

18/24

Intracoronary radiation involves irradiation of the section of artery after

balloon angioplasty. Studies show this experimental technique reduces

restenosis in your artery by 70%.

After the operation

Most people are admitted to hospital and monitored overnight after angioplasty.They are usually sent home early the next day.

Once home, avoid any type of lifting or other strenuous physical activity for a week.

Your doctor will advise you when you will be able to return to work and resume

driving and other physical activity.

If you have a stent, you will usually have to take an extra blood thinner medication

such as clopidogrel in addition to acetylsalicylic acid for at least the first few months

in order to prevent blood from clotting on the metal stent. This treatment may

continue for one year. You may also have to put off dental work for several months

due to the risk ofendocarditis (an infection of the heart).

Call your doctor if you:

experience swelling, bleeding, or pain at the insertion site

develop a fever

notice a change in temperature or colour in the arm or leg that was used

feel faint or weak

have shortness of breath or chest pain

Angioplasty or coronary arteries bypass surgery?

Coronary artery bypass grafting (CABG) is a successful but more invasive technique

for restoring blood flow to the heart. The heart is usually stopped and chilled, and the

patient is kept alive by a heart-and-lung machine. Usually strips of vein are removed

from one or both of the patient's own legs to be used as bypass grafts.

The great advantage of angioplasty is that the artery is returned to normal size without

resorting to major surgery. The drawback to angioplasty is restenosis. This is when

the artery renarrows due to scar formation and possibly further plaque formation. If

the angioplasty lasts six months, there's a good chance it's permanent, but restenosis is

far more likely after angioplasty than after a CABG.

On the other hand, angioplasty allows people to come back for more treatment. If an

artery re-narrows after CABG, there may not be enough vein or artery segments

elsewhere in the body to perform a second graft. Moreover, a second angioplasty is

far less traumatic to the body than a second open heart procedure.

8/2/2019 angio endo

19/24

Sometimes, circumstances will make the choice for you. People with many severe

blockages, multiple coronary blockages, or those who have diabetes may be better off

with CABG. Also, most hospitals don't perform angioplasty if there are several major

arteries blocked. This is because angioplasty temporarily blocks the artery completely

when the balloon is inflated. If the other arteries are also blocked, this could trigger a

heart attack. However, if you're over 80 years of age or have other serious medicalproblems, you may be considered too vulnerable for the trauma of open-heart surgery.

In that case, angioplasty may be a more attractive option, no matter how many arteries

are blocked.

Possible complications

Angioplasty is safer than bypass surgery. Less than 1% of people die from

complications of angioplasty. Non-fatal serious complications occur in 1% to 5% of

people who undergo this procedure. These complications include:

tearing of the lining of the artery resulting in total blockage and possible heart

attack - this can usually be repaired with a stent

stroke from a clot that is dislodged while the catheter is inside the body

bleeding or bruising

kidney problems, especially in people with underlying kidney disease and

diabetes - this is caused by the iodine contrast dye used for the X-ray;

intravenous fluids and medications can be given before and after the procedureto try to reduce this risk

All medications have both common (generic) and brand names. The brand name is

what a specific manufacturer calls the product (e.g., Tylenol). The common name is

the medical name for the medication (e.g., acetaminophen). A medication may have

many brand names, but only one common name. This article lists medications by their

common names. For more information on brand names, speak with your doctor or

pharmacist.

What Are the Risks of Coronary Angioplasty?

Coronary angioplasty is a common medical procedure. Serious complications don't

occur often. However, they can happen no matter how careful your doctor is or how

well he or she does the procedure. Serious complications include:

Bleeding from the blood vessel where the catheters were inserted.

Blood vessel damage from the catheters.

8/2/2019 angio endo

20/24

An allergic reaction to the dye given during the angioplasty.

An arrhythmia (irregular heartbeat).

The need for emergency coronary artery bypass grafting during the procedure

(24 percent of people). This may occur if an artery closes down instead of

opening up.

Damage to the kidneys caused by the dye used. Heart attack (35 percent of people).

Stroke (less than 1 percent of people).

Sometimes chest pain can occur during angioplasty because the balloon briefly blocks

blood supply to the heart.

As with any procedure involving the heart, complications can sometimes, though

rarely, cause death. Less than 2 percent of people die during angioplasty.

The risk of complications is higher in:

People aged 75 and older

People who have kidney disease or diabetes

Women

People who have poor pumping function in their hearts

People who have extensive heart disease and blockages in their coronary

(heart) arteries

Research on angioplasty is ongoing to make it safer and more effective, to prevent

treated arteries from closing again, and to make the procedure an option for more

people.

Complications From Stents:

Restenosis

After angioplasty, the treated coronary artery can become narrowed or blocked again,

often within 6 months of angioplasty. This is called restenosis (RE-sten-o-sis). Whena stent (small mesh tube) isn't used during angioplasty, 4 out of 10 people have

restenosis.

The growth of scar tissue in and around a stent also can cause restenosis. When a stent

is used, 2 out of 10 people have restenosis.

8/2/2019 angio endo

21/24

Stent Restenosis

The illustration shows the restenosis of a stent-widened coronary artery. In figure A,

the expanded stent compresses plaque, allowing normal blood flow. The inset image

on figure A shows a cross-section of the compressed plaque and stent-widened artery.In figure B, over time, scar tissue grows through and around the stent. This causes a

partial blockage of the artery and abnormal blood flow. The inset image on figure B

shows a cross-section of the tissue growth around the stent.

Stents coated with medicine reduce the growth of scar tissue around the stent and

lower the chance of restenosis even more. When these stents are used, about 1 in 10

people has restenosis.

Other treatments, such as radiation, can help prevent tissue growth within a stent. For

this procedure, a wire is put through a catheter to where the stent is placed. The wirereleases radiation to stop any tissue growth that may block the artery.

8/2/2019 angio endo

22/24

Blood Clots

Studies suggest that there's a higher risk of blood clots forming in medicine-coated

stents compared to bare metal stents. However, no conclusive evidence shows thatthese stents increase the chances of having a heart attack or dying, if used as

recommended.

When medicine-coated stents are used in people who have advanced CHD, there is a

higher risk of blood clots, heart attack, and death. Researchers continue to study

medicine-coated stents, including their use in people who have advanced CHD.

Taking medicine as prescribed by your doctor can lower your risk of blood clots.

People who have medicine-coated stents usually are advised to take anticlotting

medicines, such as clopidogrel and aspirin, for months to years to lower the risk of

blood clots.

As with all procedures, it's important to talk with your doctor about your treatment

options, including the risks and benefits.

Key Points

Coronary angioplasty is a procedure used to open blocked or narrowed

coronary (heart) arteries. The procedure improves blood flow to the heartmuscle.

Over time, a fatty substance called plaque can build up in your arteries,

causing them to harden and narrow. When plaque builds up in the coronary

arteries, the condition is called coronary heart disease (CHD).

Angioplasty can restore blood flow to the heart if the coronary arteries have

become narrowed or blocked because of CHD. The procedure can improve

symptoms of CHD, reduce damage to the heart muscle caused by a heart

attack, and reduce the risk of death in some patients.

Angioplasty is less invasive than surgery. General anesthesia isn't needed.

You'll be given medicines to help you relax, but you'll be awake during the

procedure. Before angioplasty is done, your doctor will need to know the location and

extent of blockages in your coronary arteries. To find this information, your

doctor will use coronary angiography. This test uses dye and special x rays to

show the insides of your coronary arteries.

Angioplasty is done in a special part of the hospital called the cardiac

catheterization laboratory.

During angioplasty, your doctor will use a thin, flexible tube called a catheter

with a balloon at the end. He or she will thread the balloon catheter through an

artery in your arm or groin (upper thigh) to the blockage in your coronary

artery. Your doctor will then inflate the balloon. This pushes the plaque

against the artery wall, relieving the blockage and improving blood flow.

8/2/2019 angio endo

23/24

A small mesh tube called a stent usually is placed in the newly widened part of

the artery. The stent helps prevent the artery from becoming narrowed or

blocked again. The stent remains in place after the procedure.

After the procedure, you'll be moved to a special care unit. While you recover,

nurses will check your heart rate and blood pressure. Most people go home the

day after having angioplasty. Your doctor may recommend lifestyle changes after angioplasty to improve

CHD and to prevent arteries from becoming narrowed or blocked again.

Lifestyle changes may include changing your diet, quitting smoking, doing

physical activity regularly, losing weight or maintaining a healthy weight, and

reducing stress. You also should take all of your medicines exactly as your

doctor prescribes.

Angioplasty is a common medical procedure. Serious complications don't

occur often. However, they can happen no matter how careful your doctor is

or how well he or she does the procedure. Complications may include

bleeding, renarrowing of the artery, blood clots, and more.

Research on angioplasty is ongoing to make it safer and more effective, toprevent treated arteries from closing again, and to make the procedure an

option for more people.

Re-narrowing of your artery (restenosis). With angioplasty alone

without stent placementrestenosis happens in as many as 30 to 40 percent

of cases. Stents were developed to reduce restenosis. The original bare-metal

stents reduce the chance of restenosis to less than 20 percent, and the use of

drug-eluting stents has reduced the risk to less than 10 percent.

Blood clots. Blood clots can form within stents even weeks or months after

angioplasty. These clots may cause a heart attack. It's important to take

aspirin, clopidogrel (Plavix) and other medications exactly as prescribed to

decrease the chance of clots forming in your stent. Talk to your doctor about

how long you'll need to take these medications and whether they can be

discontinued if you need surgery.

Bleeding. You may have bleeding at the site in your leg or arm where a

catheter was inserted. Usually this simply results in a bruise, but sometimes

serious bleeding occurs and may require blood transfusion or surgical

procedures.

Other rare risks of angioplasty include:

Heart attack. Though rare, you may have a heart attack during the procedure.

8/2/2019 angio endo

24/24

Coronary artery damage. Your coronary artery may be torn or ruptured

(dissected) during the procedure. These complications may require emergency

bypass surgery.

Kidney problems. The dye used during angioplasty and stent placement can

cause kidney damage, especially in people who already have kidney problems.

If you're at increased risk, your doctor may give you a medication to try toprotect your kidneys.

Stroke. During angioplasty, blood clots that may form on the catheters can

break loose and travel to your brain. Blood thinners are given during the

procedure to reduce this risk. A stroke can also occur if plaques in your heart

break loose when the catheters are being threaded through the aorta.

Abnormal heart rhythms. You heart may get irritated during the procedure

and beat too quickly or too slowly. These heart rhythm problems are usually

short-lived, but sometimes medications or a temporary pacemaker is needed.