DR. AIDAH ABU ELSOUD ALKAISSILINKÖPING UNIVERSITY

SWEDEN

Percutaneous Coronary Interventions

Percutaneous Coronary Interventions

The path to PTCA began in 1964, when Dotter and Judkins introduced the concept of mechanically dilating a stenosis in a blood vessel with a technique of inserting a series of progressively larger catheters to treat peripheral vascular disease.

After experimenting with this technique, Gruentzig modified the procedure by placing on the tip of a catheter a polyvinyl balloon, which was passed into a narrowed vessel and then inflated.

Because it produced a smoother luminal surface with less trauma than the Dotter- Judkins approach, this new method reduced the risk of complications such as vessel rupture, subintimal tearing, and embolism.

Percutaneous Coronary Interventions

At first, Gruentzig continued to apply his technique only to peripheral vascular lesions.

Then, after successful dilation of more than 500 peripheral lesions, he designed a smaller version of the dilation catheter for use within the coronary arterial tree.

This new design was tested initially on dogs with experimentally induced coronary artery stenoses.

After extensive canine experimentation, Gruentzig performed the first human PTCA in 1977.

Since then, considerable improvements in technique and equipment have made PTCA the treatment of choice for appropriate cases of CAD.

Percutaneous Coronary Interventions

PTCA may be used to treat patients with myocardial infarction or unstable angina, or those with lesions that occlude more than 70% of the internal lumen of a coronary artery.

PTCA is the hallmark procedure and basis of almost all other intracoronary interventions.

During PTCA, a coaxial catheter system is introduced into the coronary arterial tree and advanced into an area of coronary artery stenosis.

A balloon attached to the catheter is then inflated, increasing the luminal diameter and improving blood flow through the dilated segment.

Percutaneous Coronary Interventions

Several inflations ranging from 30 to 300 seconds are performed.

PTCA is a nonsurgical technique applied as an alternative to CABG in the treatment of obstructive CAD.

When indicated and if successful, PTCA can alleviate myocardial ischemia, relieve angina pectoris, and prevent myocardial necrosis.

Percutaneous Coronary Interventions

PTCA may be used to treat patients with myocardial infarction or unstable angina, or those with lesions that occlude more than 70% of the internal lumen of a coronary artery.

PTCA is the hallmark procedure and basis of almost all other intracoronary interventions.

During PTCA, a coaxial catheter system is introduced into the coronary arterial tree and advanced into an area of coronary artery stenosis.

A balloon attached to the catheter is then inflated, increasing the luminal diameter and improving blood flow through the dilated segment.

Percutaneous Coronary Interventions

Several inflations ranging from 30 to 300 seconds are performed.

PTCA is a nonsurgical technique applied as an alternative to CABG in the treatment of obstructive CAD.

When indicated and if successful, PTCA can alleviate myocardial ischemia, relieve angina pectoris, and prevent myocardial necrosis.

Physiological Principles

The process that leads to successful dilation is complex and not clearly defined.

Angiographic evaluation and animal and human histological studies indicate that PTCA stretches the vessel wall, leading to fracture of the inelastic atherosclerotic plaque and to tearing or cracking within the intima and media of the vessel.

This cracking or slight dissection of the inner lumen of the vessel may be necessary for successful dilation

Comparisons Between PTCA and CABG

As an alternative treatment in appropriate cases of CAD, PTCA compares favorably with CABG in terms of risk, success rate, the patient’s physical capacity after the procedure, length of hospital stay, and cost.

Mortality rates associated with first-time angioplasty and CABG are similar.

The in-hospital death rate for patients undergoing angioplasty ranges from 0% to 2%;

the CABG mortality rate ranges from 1.5% to 4%.

If a second surgical procedure becomes necessary to alleviate the symptoms of progressive CAD, the mortality and complication rates for the bypass procedure are signifi- cantly greater than for second angioplasty.

Current 7-year survival data in the Bypass Angioplasty Revascularization

Investigation (BARI) trial reveal that CABG offers a survival benefit to diabetic patients compared with PTCA (76.4% versus 55.7%).

There is no difference in the survival rates of nondiabetic patients with CABG versus PTCA (86.4% versus 86.8%).

Comparisons Between PTCA and CABG

Successful PTCA, which is defined as a significant reduction of the luminal diameter stenosis without in-hospitaldeath, myocardial infarction, or CABG, ranges from 80% to 95%, depending on the severity of the patient’s angiographicand clinical presentation.

In a study by Bentivoglio and colleagues, the cumulative 2-year survival rates were 96% and 95% among patients with stable and unstable angina, respectively, with event-free survival (i.e., no death, myocardial infarction, or CABG) in 79% and 76%, respectively.

Among patients with multivessel PTCA, the actuarial survival rates were 97% at 1 year and 88% at 5 years in a study by O’Keefe and colleagues.

At 7 years after PTCA, Dorros and associates reported a survival rate of 90% in patients with simple single-vessel angioplasty and 95% in patients with simple multivessel angioplasty.

Long-term survival data in the era of stenting should be forthcomingin the near future.

Comparisons Between PTCA and CABG

In the Coronary Artery Surgery Study, graft patency after CABG was 90% at 2 months, 82% at 18 months, and 82% at 5 years.

The 10-year survival rate was 82%.

Restenosis or patency data differ greatly between CABG and PTCA.

Within 6 months after angioplasty, 20% to 30% of lesions recur or restenose.

Intracoronary stenting reduces the incidence of restenosis by an additional 5% to 10%.

The mean occlusion rate for bypass grafts is approximately 18% during the first 5 years and 4% to 5% between 5 and 10 years.

Comparisons Between PTCA and CABG

Psychological advantages of PTCA over surgery may argue favorably for the less invasive procedure.

The emotional stress of awaiting dilation is less than that of awaiting surgery.

This reduction in anxiety, however, is partly offset by the risk of psychological crisis if the angioplasty fails and surgery—especially immediate surgery—is needed.

The psychological impact of this discouraging situation is significant, but it occurs in a relatively low percentage of cases.

Barring complications with either procedure, PTCA requires a hospital stay of 12 to 24 hours, whereas CABG requires a stay of 3 to 7 days.

Because the average hospital stay is shorter with PTCA and because PTCA is performed in the cardiac catheterization laboratory under local anesthesia, the average cost of PTCA may be substantially lower than that of CABG.

Comparisons Between PTCA and CABG

The following factors, however, can increase the cost of PTCA:

■ Complications occurring during the procedure, requiring emergency surgery

■ Lesions that recur, requiring repeat dilation, or bypass surgery

■ Surgical standby, which is provided in different levels to correspond to the risk associated with each PTCA

■ Lesions that require multiple devices to ablate the lesion

■ Complications associated with the anticoagulation regimen or arterial and venous access

A factor in favor of PTCA is the lower morbidity after the procedure compared with CABG.

Patients who have undergone PTCA often return to work within 7 to 10 days after the procedure, whereas patients undergoing CABG return to work within 6 weeks.

In conclusion, the major advantages of angioplasty over bypass surgery may include reduced mortality and morbidity, shorter convalescence, and lower cost to the patient and third-party payers.

Diagnostic Tests for PTCA andCABG Patient Selection

Before deciding between PTCA and CABG, all objective evidence of coronary insufficiency must be documented.

Noninvasive methods of evaluation that may be used before and after PTCA include standard treadmill stress testing and thallium stress and redistribution myocardial imaging.

These tests allow the physician to discover the areas of ischemia in the myocardium when the patient is subjected to stress (i.e., exercise).

The nurse should be familiar with the results of the thallium stress test indicated on the examination report because an understanding of the patient’s diagnosis and related symptoms, and thus of the reasons for interventional angioplasty therapy, promotes more informed patient care.

Diagnostic Tests for PTCA andCABG Patient Selection

Coronary arteriography with cardiac catheterization, another method of documenting coronary insufficiency, is done if the previous tests indicate coronary disease.

Although this procedure is more invasive than treadmill testing and thallium imaging, it is required to pinpoint thelocation of any stenoses and the degree of involvement of the artery or arteries.

This procedure yields a 35-mm, VHS tape cineangiogram, or digital image of the coronary artery anatomy.

The physician can then analyze closely areas of narrowing, gaining precise information to decide the mode of treatment

Equipment Features

Since the introduction of PTCA, the equipment has been continually refined, resulting in fewer contraindications and lower rates of mortality and emergency bypass surgery.

The guiding catheters used to direct and support the advancement of the dilation catheter into the appropriate coronary artery ostium have an outer diameter of 6 to 10 Fr.

Like the Judkins and Amplatz coronary angiography catheters, the tips of the guiding catheters have curves that are preshaped for selective access to either the right or left coronary artery.

Balloon dilation systems have evolved since Gruentzig’s original design, in which the guidewire tip and catheter shaft were integral.

In the early days of angioplasty, physicians were limited by catheter performance and could address lesions only in the proximal anatomy.

In 1982, Simpson introduced a coaxial “over-the-wire” system, an improvement that has become predominant in current catheter designs.

Equipment Features

The main innovation is an independently movable guidewire within the balloon dilation catheter.

This guidewire can be manipulated to select the correct vessel despite side branches and permits safe advancement of the dilation catheter across the lesion.

Currently, the available guidewires measure between 0.010 and 0.018 inch in diameter and thus usually pose little threat of interference with the blood flow through a stenosis.

Equipment Features

Coronary balloon dilation catheter shafts range in size from 1.9 to 4.2 Fr, small enough for easy passage through the guiding catheter and for visualization around the catheter during contrast injection (Fig. 18-3).

The balloon dilation catheter has one or more radiopaque markers that can be imaged by fluoroscopy (Fig. 18-4).

Thus, the physician can position the balloon accurately across the lesion.

The inflated balloon size ranges from 1.5 to 5 mm in diameter and from 10 to 40 mm in length.

The size (inflated diameter) of the balloon to be used for a particular PTCA is usually the same as the smallest-diameter segment of the coronary artery proximal or distal to the stenosis (i.e., 3-mm vessel, 3-mm balloon).

Lesion and balloon length also are approximated.

Equipment Features

The physician manually inflates the balloon with a contrast-filled, disposable inflation device that connects to the side arm or balloon lumen of the coronary dilation catheter (Fig. 18-5).

The device incorporates a pressure gauge that indicates the amount of pressure exerted against the balloon wall during inflation.

Balloon pressure is measured in pounds per square inch (psi) or atmospheres (atm).

Equipment Features

The average initial inflation is between 60 and 150 psi or 4 to 10 atm and lasts from 1 to 3 minutes.

Longer inflations may promote a smoother, more regular vessel wall as assessed by angiography and are used primarily for the treatment of major dissections and abrupt closure.

Extended inflations are performed safely with perfusion catheters that simultaneously dilate and perfuse.

Many factors must be considered when selecting the most appropriate equipment for performing PTCA.

Technological advances in angioplasty equipment have made available several balloon dilation catheter systems that have been developed to improve the success and safety associated with any PTCA.

Equipment Features

Many physicians consider the coaxial “over-the-wire” system a workhorse catheter because it can approach any anatomy well.

A physician also might select a “rapidexchange” system to accomplish more easily the dilation of a bifurcation lesion.

This type of device incorporates a “rail” system that facilitates the exchange process.

A “fixed-wire” catheter is used to reach and dilate lesions in distal, tortuousnanatomy, and its small shaft also makes it an option for the use of two coronary dilation catheters in one guiding catheter when the strategy calls for side-by-side balloons.

Each intervention also encompasses an inflation strategy.

The main elements of an inflation strategy are the duration and pressure of balloon inflation required to open a lesion.

Today, balloons are available that can withstand greater pressure for the treatment of calcific lesions.

The outcome of any PTCA is greatly affected by (1) the selection of a guiding catheter that provides a platform for the advancement of the dilation system while preserving flow to the coronary artery, and (2) the selection of a balloon dilation system that best addresses the vessel’s anatomy, the lesion’s location, and lesion characteristics.

Indications for and Contraindicationsto Percutaneous Transluminal

Coronary Angioplasty INDICATIONS When choosing to treat with PTCA (as with CABG), the physician’s purpose is to

alleviate angina pectoris unrelieved by maximal medical treatment and to reduce the risk of myocardial infarction in symptomatic patients and asymptomatic patients with severe stenosis.

Indications for PTCA have expanded as equipment, technique, and operator experience have improved.

PTCA is indicated in patients with coronary arteries that have at least a 70% narrowing.

Lesions with less narrowing are not considered appropriate for PTCA because they are equally at risk for abrupt closure, which can have serious consequences.

Patients with surgical risk factors, such as severe underlying noncardiac diseases, advanced age, and poor left ventricular function, are particularly suited for PTCA because successful dilation obviates the need for an operation that would be poorly tolerated.

INDICATIONS

An example of the wide spectrum of candidacy for PTCA is the accepted practice of treating patients with multivessel disease.

The common technique for dilating multiple lesions is to dilate the most critical stenosis first.

With successful dilation of this “culprit” lesion, remaininglesions are dilated in stages (i.e., at different intervals during the procedure or over several days).

Dilation of multiple vessels, however, is technically more demanding and carries a higher risk of complications.

INDICATIONS

Another expanded indication is the approach to treating the patient with a totally occluded vessel.

Early in PTCA practice, total occlusion disqualified a patient for the procedure because the stenosis could not be crossed with the guidewire and balloon dilation catheter without causing severe trauma to the artery.

Currently, due to refinement of equipment, technical advances, and greater physician experience, dilation of total occlusions may be attempted in appropriate candidates.

Total occlusions of short duration (i.e., 3 months or less) are easier to cross and dilate successfully than total occlusions of longer duration.

INDICATIONS

Additional candidates for PTCA are those who have undergone CABG in whom symptoms have recurred due to stenosis and graft closure or progression of coronary disease in the native vessels.

For these candidates, successful angioplasty makes second surgery, with its increased potential for complications, unnecessary.

It is thought that the proliferative disease in the graft wall generates fibrous stenosis that is much less dense than most fibrotic tissue in the native vessels, so certain vein graft stenoses respond favorably to dilation.

INDICATIONS

In the past, if a patient had an AMI documented by significant ST segment elevation, increased cardiac enzyme levels, and pain unrelieved by medication, surgery or pharmacological treatment with complete bed rest in a coronary care unit were the only treatment alternatives.

Now, if thrombosis and underlying stenosis are causing the infarction, thrombolytic therapy, PTCA, or both offer alternatives.

When a blood clot has impeded flow to the distal myocardium and thus caused an ischemic episode, a thrombolytic agent (i.e., streptokinase, urokinase, tPA) can be administered IV or directly into the coronary artery.

On successful lysis of the thrombus, dilation of the underlying stenosis often further enhances blood flow to the reperfused myocardium, reducing the risk of rethrombosis or critical narrowing caused by normal or spastic vasomotion superimposed on an organic stenosis.

Primary coronary angioplasty is a dilation of an infarctrelated coronary artery during the acute phase of a myocardial infarction without prior administration of a thrombolytic agent.

Meyer and associates first used PTCA in the AMI setting in 1982.

They reported an 81% success rate in PTCA of the infarct-related artery after intracoronary thrombolytic therapy.

In 1999, Grines and associates reported a stand-alone PTCA success rate of 97% with a patency rate of 53% 2 years after PTCA.

Parameters routinely assessed in patients selected to receive primary angioplasty are depicted in Box 18-3.

In the setting of AMI, PTCA may benefit patients deemed ineligible for traditional medical therapy.

Such patients include those in cardiogenic shock, those believed to be at high risk for bleeding complications (CVA, prolonged cardiopulmonary resuscitation [CPR], bleeding diathesis, severe hypertension, or recent surgery), and those of advanced age (older than 75 years).

Primary angioplasty does not preclude the use of thrombolytics if residual thrombus is observed.

Primary angioplasty may offer distinct advantages in reducing the length of hospital stay and eliminating the need for additional interventional in many cases.

Complications of primary angioplasty include retroperitoneal or vascular hemorrhage, other bleeding requiring transfusion, late restenosis, and early acute reocclusion.

These complications occur at the same rate as those experienced in routine elective coronary angioplasty.

CONTRAINDICATIONS

There are very few contraindications to PTCA.

Patients with left main CAD usually are not considered candidates for angioplasty.

The obvious drawback of PTCA in left main artery disease is the possibility of acute occlusion or spasm of the left main artery during the procedure, which would result in severe left ventricular dysfunction.

The only exception to this rule is the patient who has a “protected” left main artery (i.e., has had previous bypass surgery to the left anterior descending or circumflex arteries with patent grafts present).

Only then might a physician consider dilating a left main artery stenosis.

Most of these patients are still considered surgical candidates

CONTRAINDICATIONS

For high-risk patients (i.e., patients with left main vessel disease, severe left ventricular dysfunction, or dilation of the last remaining patent artery), percutaneous support devices may improve the safety of PTCA.

Among the devices and techniques being investigated are perfusion balloons, intraaortic balloon counterpulsation, coronary sinus retroperfusion, cardiopulmonary support, and partial left heart bypass

Procedure

The PTCA procedure is carried out in a sterile fashion, with the use of local anesthesia and either the Judkins (percutaneous femoral) approach or, less often, the Sones (brachial cut-down) approach (Fig. 18-6).

With the Judkins approach, the physician cannulates the femoral vein and artery percutaneously by inserting a needle (usually 18-gauge) containing a removable obturator.

The obturator then can be removed to confirm by the presence of blood flow that the outer needle is within the lumen of the vessel.

Once proper placement is established, a guidewire is introduced through the outer cannula into the artery to the level of the diaphragm.

The cannula then is removed and replaced by a valved introducer sheath.

The sheath provides hemostasis and support at the puncture site in the groin and reduces potential arterial trauma if multiple catheter exchanges are necessary.

Procedure

The guiding catheter is preloaded with a 0.038-inch J wire and introduced into the sheath.

The 0.038-inch J wire is advanced over the arch and the guiding catheter is advanced over the wire.

The 0.038-inch J wire is removed, and the guiding catheter is rotated precisely to the appropriate coronary ostium.

The procedure also may be accomplished by the Sones approach, in which a brachial cut-down is used to isolate the brachialvein and artery.

A small arteriotomy is made, and the catheter is passed to the level of the aortic arch.

Regardless of the mode of access, coronary arteriography is then carried out in both the left anterior oblique (30 degrees) and right anterior oblique (60 degrees) views.

These views allow for visualization of the heart along its transverse and longitudinal planes.

Opposing views provide a thorough assessment of both the lesion and the anatomical approach.

A “freeze frame” of each view is obtained as a road map or guide throughout the procedure.

A final lesion assessment is made, confirming lesion severity and vessel diameter for appropriate balloon sizing

If PTCA is indicated, the patient is anticoagulated with 5,000 to 10,000 units of heparin to prevent clots from forming on or in the catheter system during the procedure.

Intracoronary nitroglycerin is kept on the sterile field throughout the procedure and given intermittently as needed for vasospasm and for dilation to facilitate visualization of the culprit coronary artery.

The balloon dilation catheter is introduced into the guiding catheter through a bifurcated adapter that provides access and is a port for contrast injections and aortic pressure measurement.

The balloon dilation catheter and guidewire are advanced to the tip of the guiding catheter while their position is checked by fluoroscopy (Fig. 18-7).

The guidewire then is advanced and manipulated to negotiate the branches of the coronary artery.

Proper advancement can be confirmed by injecting contrast through the guiding catheter and fluoroscopically visualizing the coronary tree.

Once the guidewire is positioned safely beyond the stenosis, the balloon dilation catheter can be advanced slowly over the guidewire into the narrowing without risk of injury to the intima (Fig. 18-8).

Exact placement of the dilation balloon in the stenosis is facilitated under fluoroscopy by the radiopaque marker on the balloon and by contrast injections for visualization.

Initially, the balloon is inflated at 1 to 2 atm of pressure to con- firm its position.

Many PTCA balloon catheters expand at both ends and not in the center, where they are pinched by the stenosis (Figs. 18-9 and 18-10).

The central indentation usually disappears as the stenosis is dilated.

After each inflation, the physician injects a small bolus of contrast medium to assess any changes in coronary blood flow through the stenosis and to assess any increase in luminal diameter.

At this time, the need for additional inflations is determined and a waiting period of 10 to 15 minutes is observed.

Complications such as vessel recoil and abruptclosure occur most often during this early phase; however, their incidence is low, and redilation can be done readily at this time.

After dilation is complete, the guiding catheter and the balloon dilation catheter are removed. Postdilation angiography is performed to define more clearly the results of the PTCA.

Reasons for failure to complete a PTCA procedure include inability to cross the target lesion with a guidewire or dilation catheter due primarily to chronic total occlusions; inability to dilate the lesion due to rigid lesions or severe dissection; and embolization of friable vein graft material or of thrombus.

Successful dilation of a lesion commonly is defined as a reduction of the luminal diameter stenosis by about 40% or 50%.

Clinical success commonly is defined as angiographic success with clinical improvement and without significant in-hospital complications, such as death, myocardial infarction, or CABG or repeat PTCA for abrupt closure.

Angiography after successful PTCA demonstrates an immediate increase in the intraluminal diameter of the involved vessel (Fig. 18-11).

Clinical improvement of the patient is demonstrated by improved or normalized myocardial perfusion deficits, as shown by comparison of a post-PTCA thallium stress image to the pre-PTCA stress image.

Postangioplasty treadmill test results compared with the preprocedure test results reveal increased exercise endurance and a decrease in exercise-induced angina or angina equivalent.

Results

Excellent short- and long-term results have been achieved in patients undergoing coronar angioplasty.

The results vary depending on the patient’s clinical presentation(i.e., stable or unstable angina) and angiographic characteristics (i.e., subtotal or total occlusion).

Among patients undergoing either single-vessel dilation or multivessel dilation, in-hospital clinical success ranges from 85% to 95%.

In-hospital complications are low, with a reported mortality rate of 1% to 2% in both these patient groups.

Longterm survival rates are high, although repeat PTCA may be necessary for recurrent or progressive disease.

Patients with high-risk clinical or angiographic presentations have lower success rates.

PTCA, however, is often preferable to surgical revascularization because of the latter’s increased risk of mortality in patients such as older adults or those with depressed left ventricular function.

Assessment and ManagementPATIENT PREPARATION

Laboratory TestsWhen the decision has been made to proceed with

any PCI procedure, the patient usually is admitted to the hospital the day of the procedure.

The nurse should monitor all preliminary laboratory tests, including cardiac enzymes, serum electrolytes, and coagulation studies (prothrombin time and partial thromboplastin time).

Serum potassium, creatinine, and blood urea nitrogen (BUN) are particularly important.

Potassium levels must be within normal limits because low levels result in increased sensitivity and excitability of the myocardium.

The cardiac muscle also is sensitive and becomes irritable when the flow of oxygen-rich blood decreases, as happens for a controlled period of time during placement and inflation of the balloon dilation balloon across the lesion.

The irritability arising from hypokalemia or ischemia or both can give rise to life-threatening ventricular dysrhythmias.

Elevation in the levels of serum creatinine, BUN, or both may indicate problems in kidney function.

Good kidney function is important because during angioplasty, radiopaque contrast material (which allows fluoroscopic visualization of the coronary anatomy and of catheter placement) is introduced into the bloodstream.

This contrast material is a hyperosmotic solution that the kidneys must filter from the blood and excrete.

High levels of creatinine and BUN may reflect decreased renal filtration capability and vulnerability of the kidney in processing the extra load of radiopaque solution.

Instances of acute renal failure have resulted from high doses of radiopaque contrast.

The nurse should ensure that the patient is adequately hydrated, either orally or with IV solutions, to avoid falsely high electrolyte levels.

Kidney function can be monitored by trends in creatinine and BUN levels, in conjunction with measurement of urine output.

Informed Consent

The informed consent for the PCI procedure is obtained from the patient before the procedure after a detailed discussion of the potential complications, anticipated benefit, and alternative therapies.

This discussion should be conducted before any preoperative sedation.

The nurse plays an important role in answering any questions that the patient and his or her family may have regarding the procedure and follow-up care.

Preoperative Medications

Twenty-four hours before the procedure, the patient’s medications should include aspirin 325 mg once a day for its antiplatelet effect.

Medications may be prescribed to reduce vasospastic events, including nitroglycerin and calcium channel blocking agents, such as nifedipine 10 mg three times a day, and diltiazem 30 mg three times a day.

Diabetic patients taking metformin should be advised to discontinue this medication before their procedure because it is contraindicated with intravascular contrast agents.

Anticoagulants such as warfarin are often held for a number of days before the PCI procedure.

Surgical Standby

Surgical standby for PTCA is arranged before the procedure.

Surgical availability is required, but the degree to which the operating room is held for availability varies according to the patient’s risk factors, hospital policies, or both.

Many smaller community hospitals across the United States are performing PCI procedures without in-house surgical standby.

These patients are typically low risk and reside near larger academic centers that can accept the patient by immediate transfer if complications arise during the PCI.

A comparison of patients treated with PCI at hospitals without on-site cardiac surgery with those treated only with thrombolytic therapy reveals that the former group has better clinical outcomes at 1, 3, and 6 months.

NURSING MANAGEMENT DURINGPERCUTANEOUS TRANSLUMINAL

CORONARY ANGIOPLASTY

During the preparation for PTCA and throughout the procedure, nurses in the cardiac catheterization laboratory are responsible for understanding all aspects of equipment use and patient care.

They should be experienced in advanced cardiac life support and be knowledgeable about the proper administration of emergency medications and the correct application of emergency equipment, including the defibrillator, the ventilator, and the pacemaker.

They should observe and communicate with the patient intermittently and report any changes in patient status to the physician.

The nurse should monitor the ECG and arterial pressure, noting significant changes that may accompany the administration of drugs, symptoms of ischemia, or chest pain.

The nurse must recognize signs and symptoms of contrast sensitivity, such as urticaria, blushing, anxiety, nausea, and laryngospasm.

The nurse should understand the proper assembly and use of all angioplasty equipment and should be able to troubleshoot any situation that might arise.