Overview of Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation
Ischemic heart disease, a condition where the heart’s blood supply is reduced, is the main cause of death worldwide. A medical procedure known as percutaneous coronary intervention (PCI) is crucial in treating coronary artery disease, which involves blockage of the arteries supplying the heart. The majority of these procedures are performed using a medical imaging technique called fluoroscopy, which uses X-rays to visualize internal structures.
Fluoroscopy is important during this procedure because physicians need to see the exact structure of the vessels in order to target the correct area and avoid missing the diseased section of the artery. Knowing the best viewing angles for this procedure is important, as this allows physicians to cover the full length of the compromised artery and limit the amount of radiation the patient and medical team are exposed to, by reducing the time and dose of radiation used.
In this piece, we will delve into the details of percutaneous coronary intervention performed with the assistance of fluoroscopy.
Anatomy and Physiology of Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation
The heart gets its blood supply from three main arteries. The first is the left anterior descending artery, which has branches called the septal and diagonal branches. The second one is the left circumflex artery, and the third is the right coronary artery. This splits into two smaller arteries known as the right posterior descending artery and the right posterior left ventricular branch.
If a person has had heart surgery in the past to improve blood flow to the heart (a procedure known as coronary artery bypass graft), the doctors use grafts to bypass the blocked part of the artery. They usually get these grafts from other blood vessels in the body. The vessels they usually use are the saphenous vein graft, the left internal mammary artery, the right internal mammary artery, the radial artery, the gastroepiploic artery, and the inferior epigastric artery. It’s crucial that they know the location and the number of these grafts before doing an examination of the grafts.
Why do People Need Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation
Percutaneous coronary intervention (PCI), also known as angioplasty, is a nonsurgical procedure that helps improve blood flow to the heart. Here’s when you might need this procedure to better your survival rate or lessen your symptoms:
To enhance your survival:
1. If you have an unprotected left main heart artery (which supplies most of the blood to the heart) with a kind of severe heart attack known as ST-elevation myocardial infarction. The PCI is recommended if blood supply to vessel is less than ideal (i.e., TIMI III) and if this procedure can be done quicker and safer than a coronary artery bypass graft surgery (CABG).
2. If you have the same condition as stated above but experiencing a less severe heart attack (non-ST-elevation myocardial infarction) or unstable chest pain (angina) and bypass surgery cannot be performed.
3. If your unprotected left main heart artery has a stable form of coronary artery disease (a condition where heart blood vessels narrow) and if two of the given conditions exist: a) The angioplasty procedure is of a LOW risk (Syntax<22) with ostial or trunk involvement (it's an easier procedure) b) There's an increased risk of complications from surgery (your STS score, which estimates your risk of dying from heart surgery, is <5). 4. If you have a triple vessel coronary artery disease (when all three major heart arteries are narrow or blocked) with or without Proximal LAD (disease in a specific part of the heart artery). 5. If you have a two-vessel disease (two of the three major heart arteries are narrow or blocked) with a disease present in the Proximal LAD. This intervention might also be suggested if you have a two-vessel disease without Proximal LAD, or a single vessel disease with Proximal LAD. It is also an option for patients who've survived a sudden cardiac death due to presumed ischemia-mediated ventricular tachycardia (a rapid, irregular heartbeat caused by lower heart chamber dysfunction because of inadequate blood supply). To relieve your symptoms: PCI is beneficial if you frequently have angina (chest pain) despite receiving the best medical care. It is specifically recommended if: 1. You have at least one significant (>70% diameter) coronary artery disease (or more). In other words, your artery is blocked by 70% or more, and it can undergo revascularization, a procedure that restores blood flow.
2. You face the same condition as stated above, and medical management doesn’t work because of problems like medication contraindication (when a drug used could harm you), adverse effects, or personal preference.
3. You have the same condition as the first point, associated with ischemia (inadequate blood supply to the heart).
When a Person Should Avoid Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation
There are certain conditions in which performing a percutaneous coronary intervention (a non-surgical procedure used to treat the stenotic (narrowed) coronary arteries of the heart) is not adviceable:
Absolute Conditions (meaning it shouldn’t be done):
1. If a person cannot tolerate two types of antiplatelet drugs — medicines that stop blood clots from forming.
2. If a person has a severe illness that is likely to limit their lifespan to less than a year.
Relative Conditions (meaning it might or might not be done, depending on the situation):
1. If the diameter of the coronary artery (the artery supplying blood to the heart) is less than 2.5 mm.
2. If the structure of the heart is such that the procedure cannot be properly performed.
3. If there is a widespread disease in the saphenous vein graft (which is a vein taken from the leg and used to bypass a narrowed or blocked coronary artery).
Equipment used for Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation
If you’re undergoing a procedure known as fluoroscopic percutaneous coronary intervention, a few pieces of equipment are vital. This process, which treats blocked arteries in your heart, uses the following:
- A fluoroscopic machine: This machine uses X-rays to create real-time images of the inside of your body being worked upon by the doctors.
- Contrast agent: This is a special dye injected into your bloodstream which helps the doctors see your arteries more clearly on the X-rays.
- Guide catheters: These are long, thin tubes that the doctors use to reach your heart and arteries..
- Guide wires: These wires are used to help position catheters in the right spot.
- Coronary balloon: This is a small device that can be inflated once it’s in position to help open up your artery.
- Coronary stent: A stent is a small, tube-like device that’s left in your artery to keep it open after the procedure.
To ensure the safety of the medical staff performing the procedure as it involves exposure to radiation, they need to be wearing protective equipment. This includes:
- Lead apron: This is a heavy vest that blocks radiation.
- Thyroid collar: This protects the thyroid gland in your neck from radiation exposure.
- Radiation protective glasses: These glasses are specifically designed to protect the eyes from radiation.
- Radiation monitoring badges: These are worn by medical staff to measure their exposure to radiation over time.
Who is needed to perform Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation?
An intervention cardiologist is a heart doctor who performs procedures to treat heart problems. These may involve unblocking blood vessels, amongst other treatments. A radiation technician is a specialist who operates machines, like an X-ray, to help the doctor see inside your body. A cath lab technician works in a special type of lab in the hospital where heart procedures are done. They help the doctor with tools and machines during your treatment. Also, there will be a staff nurse who will take care of you before, during, and after your procedure, ensuring you are comfortable and understand what is going on.
Preparing for Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation
Before starting the procedure, the doctor will have a discussion with the patient to make sure they understand what will be done; this is known as getting ‘informed consent’. The doctor will then learn all about the patient’s medical history and do a physical check-up. This is to understand why the procedure needs to be done and to make sure the patient is ready for it. The patient will also be given a type of medicine known as ‘antiplatelets’ to prepare for the procedure.
How is Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation performed
When doctors perform a coronary angioplasty, they need to use X-ray imaging (fluoroscopy) to see the blood vessels in your heart. This helps guide them to the blockage in your artery they need to fix. Different sections of your arteries can be seen best using different views with the fluoroscope.
Here is a simplified explanation of how doctors visualize each part of your arteries when performing this procedure:
The Left Main Coronary Artery (the main artery that brings blood to the left side of your heart) can be seen best when doctors use the LAO (left anterior oblique) and RAO (Right anterior oblique) views on the fluoroscope. To see the middle part of this artery, they will also use the AP (Anteroposterior) view.
The Left Anterior Descending Artery (an artery that supplies blood to the front of your heart) is also seen best using a combination of LAO, RAO, and AP views.
The Left Circumflex Artery (an artery that goes around the left side of your heart) and the Right Coronary Artery (the main artery for the right side of your heart) also require a combination of LAO, RAO, and AP views.
When doctors need to visualize a vein graft (a new passage made to help blood flow around a blockage) to one of the arteries, the fluoroscope views will vary. For example, a graft to the LAD (Left Anterior Descending Artery) is best seen using the AP and RAO views, while a graft to the right coronary artery is most visible when using the LAO view.
Lastly, viewing the Left Internal Mammary Artery to the LAD (a common source of an artery graft) also requires certain fluoroscope views.
This may seem complex, but don’t worry – doctors have a thorough understanding of these procedures and the best views to use to ensure a successful outcome. And remember, the images are checked before and after the procedure.
Possible Complications of Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation
Percutaneous coronary intervention, a procedure to open blocked arteries, might have some complications. These can include:
1. Damaging the artery in the heart (coronary artery dissection)
2. Puncture or hole in the artery (coronary artery perforation)
3. Break up of a clot, leading it to travel through the bloodstream (distal embolization)
4. Closure of smaller branches that come off larger blood vessels (side branch occlusion)
5. Blood clot within the stent (stent thrombosis)
6. Bleeding at the site where they inserted the catheter (access site bleeding)
7. A buildup of blood collected outside of blood vessels, like a bruise (access site hematoma)
8. Sudden worsening in kidney function (acute kidney injury)
9. Stroke
10. Allergic reaction to the dye used to make your arteries visible (contrast)
Additionally, exposure to the type of X-ray used during the procedure (fluoroscopic radiation) can also lead to complications:
Tissue Reaction
* Skin Injury: The most common effect at the spot where the X-ray enters the body after percutaneous coronary intervention. It depends on how long you were exposed:
1. A few hours to a few days later: mild redness
2. A week to a few weeks later: pronounced redness
3. 4 to 8 weeks later: severe skin damage, including ulcers in rare cases
* Bone Injury: In rare cases, radiation can cause the death of surface-level bones like ribs.
* Eye Injury: A single exposure of 500 mGy of radiation can cause cataracts, typically seen one year later.
Stochastic Effects: Radiation-Induced Cancer
Radiation can, in rare cases, lead to cancer. It’s important for patients and healthcare workers to understand the risk of radiation exposure. To decrease the risk, protective measures against radiation should be used.
What Else Should I Know About Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation?
Percutaneous coronary intervention, a procedure done under X-ray guidance to unclog heart arteries, has been a common treatment for many years. It has proven to significantly decrease the health complications and death risk for patients who’ve had a heart attack compared to a treatment known as thrombolysis. Moreover, this technique is also beneficial to people with chronic coronary syndrome, a condition where blockages in the blood vessels can cause recurring chest discomfort, by improving their quality of life.
Compared to open-heart surgery, known as coronary artery bypass grafting (CABG), this procedure has several advantages. Patients usually don’t need to stay as long in the hospital, and they can start moving around sooner after the treatment. Plus, unlike with open-heart surgery, there’s no large scar left on the chest.
Advancements in this procedure over the years have led to better survival rates for patients with coronary artery disease, a condition where the heart’s blood supply is blocked or interrupted.