ASSIGNMENT

ON

TOPIC: PTCA (Percutaneous

Transluminous Coronary Angioplasty)
INTRODUCTION

Percutaneous transluminal coronary angioplasty (PTCA) also called percutaneous coronary

intervention (PCI) is a minimally invasive procedure to open blocked or stenosed coronary
arteries allowing unobstructed blood flow to the myocardium. The blockages occur because
of lipid-rich plaque within the arteries, diminishing blood flow to the myocardium. The
accumulation of lipid-rich plaque in the arteries is known as atherosclerosis. When
atherosclerosis affects the coronary arteries, the disorder is known as coronary artery disease. 
Patients with CAD usually present with exertional chest pain, or with dyspnea with exertion.
In acute myocardial infarction, there is plaque rupture with platelet aggregation, and acute
thrombus formation, which results in a sudden occlusion of the coronary artery. These
patients present with acute chest heaviness, diaphoresis, and nausea. Urgent PTCA is often
required to limit myocardial damage.

Andreas Gruentzig first developed PCTA in 1977, and the procedure was performed in
Zurich, Switzerland that same year. By the mid-1980s many leading institutions adopted this
procedure throughout the world as a treatment for coronary artery disease. PTCA is a
hallmark procedure and basis of many other intracoronary interventions. It is one of the most
common procedures performed in the United States making up 3.6% of all operating room
procedures performed in 2011.

Anatomy

The 2, main coronary arteries supplying the heart are the right and left coronary arteries. The
left coronary artery (LCA) divides into left anterior descending (LAD) and left circumflex
iliac (LCX) branches. LCA supplies blood to the left ventricle of the heart. The right
coronary artery (RCA) divides into the right posterior descending (PDA) and a (PL)
posterolateral branch. RCA supplies blood to the ventricles, right atrium and sinoatrial node.
Coronary arteries are end-arteries supplying the myocardium and blockage can lead to serious
adverse effects. Coronary artery disease occurs due to the buildup of plaque within the
coronary arteries with subsequent narrowing and blockage reducing blood flow to the
myocardium.

Indications
Indications of PTCA depend on various factors. Patients with stable angina symptoms
unresponsive to maximal medical therapy will benefit from PCI. It helps provide relief of
persistent angina symptoms despite maximal medical therapy.[2] Emergency
PTCA is indicated for acute ST-elevation myocardial infarction (STEMI) suggesting 100%
occlusion of the coronary artery. With acute STEMI, patients are taken directly to cath lab
immediately upon presentation to help prevent further myocardial muscle damage. In non-
ST-elevation myocardial infarction (NSTEMI), or unstable angina, (known as acute coronary
syndromes), patients are taken to cardiac cath lab within 24 to 48 hours.

Contraindications

PTCA has limited contraindications. Patients with left main CAD are poor candidates for the
procedure due to the risk of acute obstruction or spasm of the left main coronary artery during
the procedure. It is also not recommended for patients with hemodynamically insignificant
(less than 70%) stenosis of the coronary arteries.

Equipment

Initially, PCI was performed using balloon catheters alone. However, due to subclinical
outcomes and vessel re-stenosis, other devices were introduced including atherectomy
devices and coronary stents. Atherectomy devices used alone resulted in poor outcomes.
Coronary stents are the most widely used intracoronary devices in PTCA due to improved
clinical outcomes. Various types of stents are available including traditional bare-metal stents
(BMS) and drug-eluting stents (DES). DES has a polymer coating that prevents inflammation
and endothelial cell proliferation. Most recent DES used in the United States use sirolimus,
everolimus, and zotarolimus. The newer generation DES have reduced the incidence of late
stent thrombosis.[3] The use of antiplatelet therapy is important during the first 12
months after PTCA, allowing appropriate duration for endothelial cell formation over the
metallic stent to prevent stent thrombosis.

Personnel

A team made up of an interventional cardiologist, nurse, and radiology technologist performs

PTCA. All team members must have specialized and extensive training in the procedure.

Preparation
An interprofessional team evaluates the patients and performs pre-procedural testing to
determine candidacy for the procedure. The inquiry related to the past history of allergy to
seafood or contrast agents is vital. Important pre-procedure laboratory tests include PT and
PTT, serum electrolytes, BUN, and creatinine. The patient is required to be well hydrated.
Medication review is essential including cessation of anticoagulants if possible. Also,
common medications including NSAIDs, or ACEIs can be held to prevent worsening renal
insufficiency. The diabetes medication metformin is held prior to cardiac catheterization to
avoid worsening renal insufficiency and lactic acidosis. Fluids and food are restricted 6 to 8
hours before the procedure. When cases are performed via radial artery access, patients are
often given intra-arterial calcium channel blocker, nitroglycerin, and heparin to prevent
vasospasm. The health care provider should thoroughly explain the procedure and its
associated risks and complications to the patient to obtain a signed informed consent.

Technique

The procedure is performed under local anesthesia. Conscious sedation is routinely given to
avoid stress and calm the patient. Most commonly used approach is the percutaneous femoral
(Judkins) approach. Once the patient is anesthetized with a superficial injection of lidocaine
to the skin, and subcutaneous tissues over the right femoral artery, a needle is inserted into
the femoral artery (percutaneous access). Successful insertion of the needle is followed by
insertion of a guide wire through the needle into the lumen of the blood vessel. The needle is
then removed with the guide wire remaining in the vessel lumen. A sheath with introducer is
placed over the guide wire and into the femoral artery. Next, the guide wire and introducer is
removed, leaving the sheath in the vessel lumen. This provides easy access to the femoral
artery lumen. Next, a long narrow tube, known as the "diagnostic catheter," is advanced
through the sheath with a long guidewire in the catheter lumen. The diagnostic catheter
follows the guide wire and is passed retrograde through the femoral artery, iliac artery,
descending aorta, over the aortic arch to the proximal ascending aorta. The guide wire is
removed leaving the tip of the diagnostic catheter in the ascending aorta. The diagnostic
catheter is attached to a manifold with a syringe. The manifold allows the ability to inject
contrast, check inter-arterial pressure, and administer medications.

The diagnostic catheter is then manipulated into the ostium of the left main coronary artery,
or right coronary artery. Contrast dye is injected, and cineangiography images are obtained in
multiple views of both arteries. If severe stenosis exists in one of the arteries, PTCA can be
performed. The diagnostic catheter is removed and exchanged for a similar guide catheter.
Guide catheters have a larger luminal diameter for ease of passage of wires and balloons
during angioplasty. After the guide catheter is placed in the ostium of the respective artery, a
PTCA guide wire is advanced through the catheter and across the stenosis. Once the PTCA
guide wire is passed across the stenosis, it is left in place until the end of the procedure. A
balloon wire can be placed over the PTCA guide wire and advanced until the balloon is
directly over the stenosis. The cardiologist controls the direction and movement of the PTCA
guide wire, and balloon wire by twisting the part of guide wires that sit outside the patient.
The balloon is then inflated and deflated repeatedly until the artery is patent. In most
instances, a stent is required. The balloon wire is removed and exchanged for a stent. A stent
is a latticed metal scaffold that is delivered crimped over a balloon of a balloon wire. The
stent is then placed in the position of the stenosis, and the balloon expanded. Once the stent is
expanded, it cannot be removed from the artery. The balloon is deflated, and the stent
remains in place. The stent can maintain long-term patency. Repeated injections of contrast
media are utilized to check for patency of the artery.

Upon successful insertion of the stent and expansion of the vessel, the balloon wire is
removed. Lastly, the PTCA guide wire is removed. During the procedure, anticoagulation is
administered to prevent the formation of clots. The entire procedure can take from 30 minutes
to 3 hours depending upon the technical difficulties of the case.

Complications

PTCA is widely practiced and has risks, but major procedural complications are rare. The
mortality rate during angioplasty is 1.2%. People older than the age of 65, with kidney
disease or diabetes, women and those with massive heart disease are at a higher risk for
complications. Possible complications include hematoma at the femoral artery insertion site,
pseudoaneurysm of the femoral artery, infection of skin over femoral artery, embolism,
stroke, kidney injury from contrast dye, hypersensitivity to dye, vessel rupture, coronary
artery dissection, bleeding, vasospasm, thrombus formation, and acute MI. There is a long-
term risk of re-stenosis of the stented vessel.

Clinical Significance

PTCA is performed under local anesthesia and serves as an alternative to coronary artery
bypass surgery (CABG). In comparison to CABG, PTCA is associated with lower morbidity
and mortality, shorter convalescence and lower cost. It can significantly improve blood flow
through the coronary arteries in about 90% of patients with relief of anginal symptoms and
improvement in exercise capacity. It effectively eliminates arterial narrowing in most cases.
Different modeling studies presented different conclusions regarding the cost-effectiveness of
PTCA and CABG in patients of myocardial ischemia that do not respond to medical therapy

Enhancing Healthcare Team Outcomes

PTCA is not an easy procedure, and despite the advances in technology, it has risks and
complications. All patients need to be educated about the procedure and its potential
complications. Maintaining a healthy diet, exercising, and reducing stress are important post-
procedural measures to reduce the risk of recurrences and complications. The heart team
illustrates an excellent example of patient-centered care. Experts from different fields of
medicine come together to provide the best solution for each patient

CONCLUSION

Angioplasty is a procedure that opens up a narrowed or blocked artery in your heart. It is a

treatment that can work well for people who have this problem. Angioplasty is done in a
hospital, but it is not surgery. You will not have any incisions (cuts) in your chest or heart.
Angioplasty is a treatment, but not a cure for coronary disease. Coronary disease needs
lifelong management. Other ways to control your disease is by taking medicines prescribed
by your doctor to help if you have high blood pressure, high cholesterol(a fat in your
blood) ,high blood sugar leading a healthy lifestyle.

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