Angioplasty_ Atherectomy and Stenting - Phil Moyer MD by changcheng2


									                                                  Dr. Philip Moyer M.D.

                                              Patient Education Literature
We recommend that you read this handout carefully in order to prepare yourself or family members for the
proposed procedure. In doing so, you will benefit both the outcome and safety of the procedure. If you still have
any questions or concerns, we strongly encourage you to contact our office prior to your procedure so that we
may clarify any pertinent issues.

               Angioplasty, Atherectomy and Stenting

What is angioplasty, atherectomy and stenting?
During an angioplasty, your vascular surgeon inflates a small balloon inside a narrowed blood vessel.
The balloon helps to widen your blood vessel and improve blood flow. After widening the vessel with
angioplasty, your vascular surgeon sometimes inserts a stent depending upon the circumstances. Your
surgeon may also choose a technique known as atherectomy to help open blood flow in the vessel.
Stents are tiny metal mesh tubes that support your artery walls to keep your vessels wide open.

Angioplasty, atherectomy and stenting are usually done through a small puncture, or sometimes a small
incision, in your skin, called the access site. Your vascular surgeon inserts a long, thin tube called a
catheter through this access site. Using X-ray guidance, your physician then guides the catheter through
your blood vessels to the blocked area. The tip of the
catheter carries the angioplasty balloon or stent.

Angioplasty most often is used to treat peripheral arterial
disease (PAD), which is another name for hardening of
the arteries supplying blood to your limbs or to organs in
your body other than your heart. Angioplasty can also be
used, in some circumstances, to treat narrowed areas in
your veins, which are blood vessels that drain blood out
of your limbs or organs and return the blood to your
lungs and heart.

Your arteries are normally smooth and unobstructed on
the inside, but as you age, plaque can build up in the
walls of your arteries. Cholesterol, calcium, and fibrous
tissue make up this plaque. As more plaque builds up,
your arteries can narrow and stiffen. This process is
called atherosclerosis, or hardening of the arteries.
Eventually, enough plaque builds up to reduce blood
flow through your arteries causing pain or damage to the
part of the body that the artery supplies.

Depending upon the particular circumstances, your
Patient Education Literature – Angioplasty, atherectomy and stenting
physician may recommend angioplasty or atherectomy as an alternative to bypass surgery, which also
treats narrowed arteries. For certain types of blockages, angioplasty or atherectomy has some advantages
when compared to bypass surgery. For example, neither requires a large incision. Because of this,
angioplasty and atherectomy patients usually spend less time in the hospital and recover at home faster
than bypass surgery patients. Also, your physician can usually perform these while you are awake,
whereas bypass surgery requires general or regional anesthesia. Nevertheless, in some circumstances,
especially for extensive PAD, bypass surgery may be a better option. Your vascular surgeon will help
you decide what alternative is best for your particular situation.

How do I prepare?
First your physician asks you questions about your general health, medical history, and symptoms. In
addition, your physician conducts a physical exam. Together these are known as a patient history and
exam. As part of your history and exam, your physician will ask you if you smoke or have high blood
pressure. Your physician will also want to know when and how often your symptoms occur, and their

Next, your physician will order tests to show how much plaque has built up in your arteries. These tests
can help your physician determine whether you need an angioplasty or some other form of treatment.
The choice of test depends on the blood vessel in question and not all of the tests need to be used for
every situation.

These tests include:

         Pulse volume recordings (PVRs)
         Duplex ultrasound
         Magnetic resonance angiography (MRA)
         Computed tomography (CT) scan

If these tests show that your arteries are moderately to severely narrowed, your vascular surgeon may
also plan a test called angiography. An angiogram directly shows your blood vessels on an X-ray and
may also provide an opportunity to treat the narrowing with angioplasty at the time of the angiogram.
During angiography, your vascular surgeon inserts a long, thin tube called a catheter into an artery in
your groin or arm after first making the area numb with a local anesthetic. Using X-ray guidance, your
physician then guides the catheter through your blood vessels to the blocked area and injects a dye that
allows the arteries to be seen on the X-ray. The dye is later eliminated in your urine after it is filtered out
by your kidneys.

Your vascular surgeon will give you the necessary instructions you need to follow before the procedure,
such as fasting. Usually, your vascular surgeon will ask you not to eat or drink anything several hours
before your procedure. Your vascular surgeon will discuss with you whether to reduce or stop any
medications that might increase your risk of bleeding or other complications. If you have any allergies to
contrast dye, which is used in angiography, you should tell your vascular surgeon at this time. Since the
contrast dye may contain iodine, you should also let your vascular surgeon know if you have allergies to
iodine or shellfish.

Before your procedure, your physician may order tests to check your kidney function as well as your
blood's ability to clot. In addition, he or she may insert an IV to deliver fluids. Depending upon the

Patient Education Literature – Angioplasty, atherectomy and stenting
circumstances, the angioplasty or atherectomy procedure may sometimes be performed at the time of the
initial angiogram or later on as a separate procedure.

Am I a candidate for angioplasty, atherectomy and stenting?
You may be a candidate for angioplasty, atherectomy and stenting if you have moderate to severe
narrowing or blockage in one or more of your blood vessels. Usually, you will also have symptoms of
artery disease, such as pain or ulceration, in one of your limbs.

If you have extremely hard plaque deposits, blockages that contain blood clots or a large amount of
calcium, extensive or particularly long blockages, blood vessel spasms that don't go away, or complete
blockages that cannot be crossed with the catheter, you probably are not a good candidate for

Am I at risk for complications during angioplasty and stenting?
Complications to angioplasty, atherectomy and stenting may include reactions to the contrast dye,
weakening of the artery wall, bleeding at the access puncture site in the vessel or the angioplasty site, re-
blocking of the treated artery, and kidney problems. Additionally, blockages can develop in the arteries
downstream from the plaque if plaque particles break free during the angioplasty procedure. If severe,
these can lead to worsening of the blood flow.

If you have diabetes or kidney disease, you may have a higher risk of complications from the contrast
dye, such as kidney failure. In the case of kidney disease, sometimes pre-treatment with medications or
fluids may decrease the impact on your kidneys.

People with blood clotting disorders also may have a higher risk of complications from the procedure. If
the plaque deposits in your arteries are especially long, you may have a greater chance of your artery
closing up again after angioplasty and stenting.

What happens during angioplasty,
atherectomy and stenting?
Your physician will usually insert the angioplasty
catheter through a small puncture point over an artery in
your groin, your wrist, or your elbow. Before the
insertion, he or she will clean your skin and shave any
hair in the immediate area. This is done to reduce your
risk of infection. Your physician numbs your skin and
then makes a small cut or puncture to reach the artery
below. Although you may be given some mild sedation,
your vascular surgeon will usually want you to stay
reasonably alert to follow instructions and describe your
sensations during the procedure.

Your vascular surgeon then inserts a guide wire or a
guide catheter into your artery. Using a type of x ray that
projects moving pictures on a screen, your physician
Patient Education Literature – Angioplasty, atherectomy and stenting
guides the catheter through your blood vessels. Because you have no nerve endings in your arteries, you
will not feel the catheters as they move through your body.

                                                         Next, your vascular surgeon will insert a balloon catheter over
                                                         the guide wire or through the guide catheter. The balloon catheter
                                                         carries a deflated and folded balloon on its tip. Your vascular
                                                         surgeon guides the balloon catheter to the narrowed section of
                                                         your artery. He or she partially inflates the balloon by sending
                                                         fluid through the balloon catheter.

                                        Your vascular surgeon watches the x ray screen for signs of a
                                        pinch in the balloon. Then, your vascular surgeon will inflate the
                                        balloon more, until the pinch caused by your artery flattens out.
When the balloon is full, your vascular surgeon may deflate and re-inflate it repeatedly to press the
plaque against your artery walls. Usually, this process takes a few minutes. Sometimes, if you have a
severe blockage, your physician may need to inflate and deflate the balloon longer.

Your artery may stretch and your blood flow through the artery stops when the balloon is pushing your
artery open. This may cause pain. However, the pain should go away when your vascular surgeon
deflates the balloon and normal blood flow resumes. Make sure to tell your physician if you experience
any symptoms during angioplasty.

There is a risk that your artery will re-narrow or become blocked again at the site where the balloon was
inflated. This can happen soon after the procedure, or months to years later. Re-narrowing of your artery
is called restenosis, and if your artery suddenly becomes blocked again it is called re-occlusion.
Restenosis can happen when scar tissue builds up inside your arteries where the balloon compressed
your plaque deposits.

There are times when a blood vessel may have blockage in it
which your vascular surgeon may feel could be opened better
with an atherectomy. With an atherectomy a hard device is used
to either bore out or cut hard plaque. After angioplasty or
atherectomy, your vascular surgeon will sometimes need to use a
stent to brace the artery open to prevent re-occlusion. A stent is a
tiny mesh tube that looks like a small spring, and comes in a
variety of sizes. To place a stent, your physician removes the
angioplasty balloon catheter and inserts a new catheter. On this
catheter, a closed stent surrounds a deflated balloon. Your
vascular surgeon guides the stent through your blood vessels to
the place where the angioplasty balloon widened your artery.
Your physician inflates the balloon inside of the stent. This expands the stent. Your physician then
deflates and removes the balloon. The stent remains in place to support the walls of your artery. Your
artery walls grow over the stent, preventing it from moving. Although stents help prop open your
arteries, scar tissue sometimes can eventually form around stents and cause restenosis.

A new type of stent is coated with drugs. These drugs may help prevent scar tissue from forming inside
a stent. Studies have shown that these new stents may be more likely to prevent restenosis than ordinary,

Patient Education Literature – Angioplasty, atherectomy and stenting
non-coated stents. In the United States, physicians currently use drug-coated stents in coronary arteries.
Experts are still testing drug-coated stents for use in other arteries.

Once your vascular surgeon finishes angioplasty, atherectomy and stenting, he or she removes all of the
catheters from your body. If blood-thinning medications have been used, your physician may leave a
short tube, called a sheath, in your artery for a short time until the medications have worn off sufficiently
to allow the puncture site to seal over when the sheath is removed.

Eventually, your physician removes the sheath and presses on the puncture area for 15 to 30 minutes to
prevent bleeding. Sometimes, instead of pressing, your physician may close the area with a device that
functions like a tiny cork, or he or she may use stitches.

Angioplasty atherectomy and stenting usually takes between 45 minutes and 3 hours, but sometimes
longer depending upon the particular circumstances.

What can I expect after angioplasty, atherectomy and stenting?
Usually, you will stay in bed for 6 to 24 hours after your procedure. During this time, your vascular
surgeon and the hospital staff closely monitor you for any complications. If your physician inserted the
catheters through an artery in your groin, you may have to hold your leg straight for several hours.
Similarly, if your arm was used, then you will need to hold it still to minimize the risk of bleeding.
Fluid intake is important. Most patients will go home the same day of surgery. Some patients may need
to stay overnight if there are problems with excessive bleeding or difficulty with pain control or nausea.
You will be sent home with a prescription for pain medicine. This is a narcotic and will affect your
ability to drive or operate machinery. It is ILLEGAL to drive while taking this medicine. Most of the
pain resolves after the first 24-36 hours but may persist for 4 to 5 days. Continue to drink plenty of

If you notice any unusual symptoms after your procedure, you should tell your vascular surgeon
immediately. These symptoms include leg pain that lingers or gets worse, a fever, shortness of breath, an
arm or a leg that turns blue or feels cold, and problems around your access site, such as bleeding,
swelling, pain, or numbness.

After you return home, your vascular surgeon will give you instructions about everyday tasks. For
example, you should not lift more than about 10 pounds for the first few days after your procedure. You
should drink plenty of water for 2 days to help flush the contrast dye out of your body. You can usually
shower 24 hours after your procedure, but you should avoid baths for a few days.

Your physician may prescribe aspirin or other medications that thin your blood. These medications will
help prevent clots from forming on your stent. Your physician may also ask you to follow an easy
exercise program, like walking.

You will be asked to schedule a time to see your physician after the procedure. At this appointment,
your physician may check your blood to make sure your medications are at the right dosage. He or she
may also use tests to see how blood is flowing through your treated artery.

Patient Education Literature – Angioplasty, atherectomy and stenting
Are there any complications?
Serious complications are unusual following angioplasty and stenting but, nevertheless, can occur.

Less serious complications include bleeding or bruising where your vascular surgeon inserted the
catheters. Sometimes, the hole created by the catheter does not completely close. This can create a false
channel of blood flow. Rarely, an abnormal connection can form between an artery and a vein at the
place where the catheter was inserted. These problems usually go away. However, if you have any
serious symptoms, your vascular surgeon can treat you.

You may have an increased risk for blood clots forming along your stent, especially in the first month
after your procedure. To reduce this risk, your physician may prescribe medications that thin your blood.

As more time passes after your angioplasty and stenting, restenosis becomes more likely. Stents,
especially drug-coated stents, may reduce this risk. However, in some cases, you may need a repeat
angioplasty or a bypass surgery if a restenosis develops.

Serious, but unusual complications include:

         Reaction to contrast dye
         A clot in the artery that your physician treated
         A torn or weakened blood vessel
         A large blood collection called a hematoma
         Kidney problems
         Damage to the lining of the artery (called dissection)
         Blockages developing in arteries downstream from the treated artery from particles of the plaque
          breaking free (called embolization).

We provide this literature for patients and family members. It is intended to be an educational supplement that
highlights some of the important points of what we have previously discussed in the office. Alternative treatments,
the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to face

Final visit:
You should see your surgeon for an office visit approximately one to three weeks after the surgery. Please do not
hesitate to contact your doctor at anytime if things do not appear to be going smoothly.

Patient Education Literature – Angioplasty, atherectomy and stenting
                                                           Consent for Procedure:

I ________________________________ have read the above description of my procedure. I understand the
indications, risks and benefits of surgery listed on this form and explained by my surgeon. I agree to undergo
angioplasty, atherectomy and/or stenting and any other indicated procedures. I have had an opportunity to ask
questions and have received all the information I need to make this decision.

____________________________                            _________________________________   ___________________
Patient Signature                                             Surgeon Signature                    Date

Witness Signature

Patient Education Literature – Angioplasty, atherectomy and stenting

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