Coronary Angiography
A diagnostic procedure to image blood vessels of the heart. It can be done through wrist (transradial) or groin (transfemoral). Blood vessels are cannulated by tube called as catheter and dye is injected inside blood vessels and videos are taken. Based on findings of angiography further treatment is decided.
Femoral Angioplasty
It is treatment of heart blood vessel blockages through access from groin. It is the older form of angioplasty.It will need patient to be immobilized for 6 to 8 hours after procedure.
Primary Angioplasty
Heart attack is because of thrombus (Clot) formation inside diseases blood vessel narrowed by cholesterol deposition.
Patient presenting early during heart attack can be directly treated with emergency angioplasty called as Primary Angioplasty.
Here last thrombus causing heart attack was aspirated from the blood vessel followed by stenting.
Rotablation Angioplasty
Some patients have blockages with added calcium in blood vessel wall, making passage of stent impossible. Such patients can be treated by a process called Rotablation where the calcium inside blood vessel wall is cut with diamond coated burr to make the lesion soft so that stent can pass. Here a 75yr old gentleman was successfully treated with rotablation to LAD vessel followed by 2 stent deployment. Patient is doing fine since procedure done in year 2016.
Tortrous RCA
Some blood vessels are tortrous by birth blockage of this arteries require complex angioplasty since the vessel has multiple turns.
Here tortrous RCA angioplasty after heart attack was done with good final result.
Bifurcation
It means presence of major blockage near origin of another big vessel, angioplasty of this blockages is highly skilled, sometime closure of neighboring vessel can occur during angioplasty.
Here complex angioplasty of major vessel LAD its branch (Diagonal) was done using multiple balloons and stents with good final result.
ISR
Medicated stent carry 3 to 5% risk of stent blockage due to new cholesterol deposition inside the stent from various reasons.
Here RCA stent put 7 years ago by another cardiologist was blocked. Patient come with fresh heart attack. Additional long stent was placed inside previous stent with good final result. Few of these patients may require bypass surgery though.
LMCA Stenting
Left main is a most important blood vessel supplying nearly 90% of heart muscle. Blockage of this vessel and its close by branches (LAD & LCX) is a high-risk case which mostly goes for Bypass surgery in few patients’ angioplasty possible or necessary. Here left main, LAD & LCX complex angioplasty was done with good final result.
Patent Stent
All drug-coated stents carry a 3-5% risk of restenosis that is a new blockage inside the stent due to poor control of risk factors and noncompliance with prescribed medicines and lifestyle.
Here a middle-aged female who suffered a heart attack treated with stenting has a patent (normal) stent after one year demonstrated with check angiography done after 1 year.
FFR Guided Angioplasty
FFR is a technology used for borderline blockage cases before going ahead with stenting. Here a middle age patient with 100% occlusion in LCX with borderline blockage in LAD and first Diagonal (branch of LAD) was taken up for angioplasty.
LCX been 100% blocked obviously needed stenting. Whereas LAD, Diagonal bifurcation that was borderline was evaluated with FFR.FFR measures blood pressure before and after the blockage and calculate a ratio. If the ratio is below 0.8 angioplasty is needed. Ratio above 0.8 angioplasty can be safely deferred. Here both LAD and Diagonal branch FFR was clearly above 0.8 hence stenting was not needed.
Triple Vessel Angioplasty with CTO
Triple vessel disease can be treated with Bypass Surgery (open heart surgery) is most cases. However, it is possible to do triple vessel angioplasty in selected cases. Here a patient with triple vessel disease with CTO (chronic total occlusion) in LAD branch was treated with staged angioplasty where in first stage LAD CTO was treated Along with LCX (both left sided heart vessels).
RCA (Right coronary artery) blockage was treated after 1 month in second stage with 2 stents and IVUS guidance. Patients heart pump also improved after second angioplasty.
Triple Vessel Angioplasty with Heart Failure
In some patients due to critical blockages and past heart attack, heart pump becomes very weak and patients responds poorly to medicines.
Here an elderly patient with heart attack and multivessel disease with recurrent episodes of heart failure admission was successfully treated with angioplasty to all 3 blood vessels of the heart. There was improvement in heart pumping and decrease in Mitral valve leak after second angioplasty.
Angioplasty after old CABG
Rarely arteries of the heart treated by bypass surgery get blocked months or years after the surgery. In such cases, the option is either redo-Bypass surgery or to treat the new blockage with angioplasty. The second bypass is a highly skilled but risky surgery. In most cases, it is possible to treat the new blockage by angioplasty. Here the venous grafts done 10 yrs. ago got blocked. The patient was successfully treated with angioplasty to the native LCX and RCA artery.
ANOMALOUS VESSEL ANGIOPLASTY
Some vessels have unexpected origins and courses making routine angioplasty difficult. These vessels need special catheters and skilled wiring to cross the lesion before stenting. Here anomalous RCA was engaged with a special catheter, wiring done skilfully, 2 wires used for support followed by balloon dilatation and stenting.
CTO
Chronic total occlusion (CTO) means the vessel is 100% occluded for 3 months or more ,earlier bypass was the only option for these patients.
Now due to advance in technology it is possible to do angioplasty for these patients. These vessels mostly need multiple wires to cross the lesion and multiple balloons to open the vessel before stenting. Here RCA CTO was opened with used of 3 wires 3 balloons and 2 stent placed .
EP Study and RFA
Abnormalities of heart beat like SVT are due to presence of abnormal fibre inside conducting system of the heart which causes heart rate to suddenly rise to dangerous levels .EP Study (electrophysiological study) is the method to tracing and diagnosing these abnormal fibres. These can be treated with RFA (radio frequency ablation) where these abnormal fibres are treated with laser current. Here 84 yrs. old lady with SVT was successfully treated with RFA after EP study.
FFR Guided Angioplasty after Heart Attack
FFR technology help us to now the significance of borderline looking blockages. Here a diabetic patient presenting with Heart attack of Right coronary artery also having tight blockage on LAD artery and borderline blockage in LCX artery was treated in 2 stages. In first stage the RCA was treated since it caused the heart attack. In second stage the tight block in LAD was treated with stenting of LCX was found to be normal hence LCX angioplasty was deferred (not needed).
OSTIAL LEFT MAIN STENTING
Left main blockages are a dangerous subset of coronary artery disease causing compromised blood flow to a large section of heart muscle. These were traditionally treated with bypass surgery, however due to advancement of technology it is possible to treat them with angioplasty. Here isolated ostial left main blockage was successfully treated with highly skilled angioplasty.
AWMI SHOCK
Shock is a dreaded complication of heart attack, where heart pumping has severely weakened resulting in low blood pressure, carrying nearly 50% risk of death.
Angioplasty in shock is high risk. Most patients need the support of injection to increase BP, few may need devices like IABP or ECMO to improve BP.
Here 75 year old lady in cardiogenic shock with 80% blocked at LAD origin underwent successful angioplasty with subsequent improvement in heart pumping & blood pressure.
PERIPHERAL ARTERY ANGIOPLASTY
Just like arteries of the heart ,other
blood vessel of body can get blocked with cholesterol deposition.
The process of angioplasty remains same(
passing wire across the blocked segment,dilatation with balloon followed by
stenting.Here right subclavian artery
supplying blood to right arm was 100% blocked.It required additional filter to
brain vessel to prevent clot migration to brain during stenting.
After angioplasty full blood supply to
right arm was restored, stroke was prevented by use of temporary filter used in
carotid artery.
ANGIOPLASTY IN OCTOGENARIAN
Most elderly above 80 year tend to have multiple blockages. Sometimes there can be a discrete blockage causing chest pain or heart attack.Here 83 years old lady with severe chest pain not responding to medicines underwent angiography by radial artery route( wrist access) followed by successful angioplasty in same sitting .
IVUS guided PCI
IVUS(intravascular ultrasound) is ultrasound of the blood vessels of the heart where a small ultrasound probe is passed inside the blood vessel to see the disease in real time sonography image helps with sizing of blood vessel, knowing calcification of vessel wall, knowing stent size ,results of stent deployment.It also helps to decrease contrast volume needed for angioplasty. Here 83 yrs old gentleman with renal failure and 4 blockkages was treated with 4 stents under IVUS guidance with only 50 ml of contrast used.
OCT FOR VULNERABLE PLAQUE
Vulnerable plaque are blockages with thin fibrous cap with can rupture and cause thrombus formation and subsequent MI.Here 40 yrs old manager with long working hours presented with NSTEMI, CAG showed borderline lesion of 50-60% with haziness of thrombus. OCT(Optical coherence tomography) was done to evaluate the lesion and need for stenting .luckily the lesion was stable and stenting was deferred .Patient put on antiplatelets agents and high dose statins advised close OPD follow up.
CROSSOVER STENTING
Mostly ostial LAD lesion are associated with distal left main disease, making angioplasty difficult, challenging and high risk as well. These cases which were always treated by bypass surgery in past are now treated with crossover stenting with IVUS guidance. Here 64 yr male with NSTEMI and tight lesion from ostial to mid LAD was treated with 2 stents from Left main to mid LAD with IVUS support with excellent end results.
ANGIOPLASTY WITHOUT STENT
Yes it is possible in some case to perform successful angioplasty without use of metallic or drug coated stent , this to to avoid metal load in native artery.Here a 25 yr old diabetic male presented with anterior wall MI(AWMI).CAG showed thrombotic lesion in proximal LAD and tight lesion in distal LAD. The thrombus in proximal LAD was aspirated there was only plaque rupture in proximal LAD without significant stenosis(Vulnerable Plaque)and distal LAD lesion was treated with drug coated balloon(DEB) with good end results . Patient remains asymptomatic in one year of follow up now.DEB can also be used to treat small size vessels, side branch of bifurcation and focal in -stent restenosis .
PRIMARY ANGIOPLASTY IN TEENAGER
A 17 yrs old college student come with dull chest pain , ECG showed subtle changes in anterior leads, Echo should regional wall motion abnormality(RWMA) and cardiac enzymes ( CPKMB and troponin) were high. CAG( coronary angiography) showed 100% occlusion in proximal LAD with thrombus .Patient underwent successful angioplasty after thrombus aspiration. Risk factors for blockages in such a young age were obesity, sedentary lifestyle, high cholesterol and junk food habits .
TAVI IN OLD AVR( VALVE IN VALVE TAVI)
Aortic stenosis is a common condition in middle age and elderly. Mostly as a sequela of congenital bicuspid aortic valve or age-related degenerative affection of aortic valve, rarely due to rheumatic heart disease or radiation. Here a 76 yrs old with two old AVR (aortic valve replacement ) surgeries came with restenosis of second bioprosthetic aortic valve and recurrent heart failure admissions. She underwent successful TAVI (Transcatheter aortic valve implantation) through femoral artery access rather than high-risk open-heart surgery. TAVI was done for valve in valve technique using balloon expandable bioprosthetic valve.
TAVI FOR DEGENERATIVE AORTIC STENOSIS
Aortic stenosis in elderly is common due to degenerative calcification.
Here 82 yrs old gentleman with recurrent heart failure admission, atrial fibrillation secondary to severe degenerative Aortic stenosis was successfully treated with self-expandable valve with good end results.
DUAL CHAMBER PACEKMAKER
The heart beat starts in natural pacemakers of the heart called SA node and AV node. Many times due to aging or other degenerative conditions these natural pacemaker don’t fire at expected rate , putting the patient at risk of bradycardia( low heart rate) , heart failure and syncope. We treat this condition by device called permanent pacemaker which is a battery implanted below the skin of chest and its leads(wires) are screwed in right side chambers of the heart through veins without opening the chest wall.Sutures on skin are removed after 15 days .
Pacemaker
This is treatment of slow or abnormal heart beat with device called pacemaker. It has a battery implanted on the chest below the skin and the leads (wires) are screwed to heart chamber to provide a very low current to the heart to increase heartbeat.
IVUS Guided PTCA
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Transradial Angioplasty
If the blockage on heart blood vessels is 70% or more than patient is advised angioplasty to the blood vessel as a treatment. Here is diseased segment is dilated with balloon followed by stent deployment .Transradial (through wrist) is convinent ,less bleed ,less pain and early mobility to the patient than femoral(groin) angioplasty.
EP Study RFA
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