Carotid Artery Stenting

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Ambrose Montgomery
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1 Disclaimer This movie is an educational resource only and should not be used to manage cardiovascular health. All decisions about the management of Carotid Artery Disease must be made in conjunction with your Physician or a licensed healthcare provider.

2 MULTIMEDIA HEALTH EDUCATION MANUAL TABLE OF CONTENTS SECTION CONTENT 1. Normal Heart Anatomy a. Introduction b. Heart Anatomy 2. Carotid Artery Disease a. What is Carotid Artery Disease? b. Risk Factors c. Signs and Symptoms d. Diagnosis e. Conservative Treatment Options 3. a. Introduction b. How is it done? c. Post Operative Guidelines d. Risks and Complications

3 INTRODUCTION is a minimally invasive medical procedure to treat narrowed or blocked carotid arteries, the arteries in the neck that supply blood to the head. The procedure involves inserting a catheter into the groin and advancing it to the carotid arteries in the neck. By inflating a small balloon inside the artery and then placing a metal mesh stent, the narrowed or blocked artery is opened thereby increasing blood flow to the brain. This procedure may be performed on an emergency basis following a ministroke or stroke, or an elective basis when conservative treatment measures have failed to relieve symptoms of Carotid Artery Disease. To learn more about it is important to understand the anatomy of the heart.

Vena Cava The vena cava is a large vein that brings deoxygenated (impure) blood back to the heart and empties it into the right atrium. Vena Cava (Refer fig. 1) (Fig.

4 Normal Heart Anatomy: Unit 1: Normal Heart Anatomy The main function of the heart is to deliver oxygen-rich blood to every cell in the body. The arteries are the passageways through which the blood is delivered to the cells in the body and the veins are the passageways through which the blood is collected and returned to the Heart. Vena Cava The vena cava is a large vein that brings deoxygenated (impure) blood back to the heart and empties it into the right atrium. Vena Cava (Refer fig. 1) (Fig. 1) Atria There are two atria (right and left) that are two of the four muscular chambers of the heart. The right atrium collects the impure blood from the vena cava and delivers it to the right ventricle. This delivery is regulated by the tricuspid valve. The left atrium collects the oxygenated blood from the lungs via the pulmonary veins and delivers it to the left ventricle. This delivery is regulated by the mitral valve. (Refer fig. 2) Atria (Fig. 2) Ventricles There are two ventricles (right and left) that are two of the four muscular chambers of the heart. The right ventricle collects the impure blood from the right atrium and delivers it to the lungs for purification (oxygenation). The pulmonary valve regulates this delivery. (Refer fig. 3)

Ventricles The left ventricle collects the pure blood from the left atrium and delivers it to the aorta (main artery) from where it is pumped to

3) Pulmonary Arteries As part of the pulmonary circulation, pulmonary arteries carry the deoxygenated blood from the right ventricle to the

4) Pulmonary Veins After oxygenation in the lungs, blood is brought back to the heart by pulmonary veins and delivered to the left atrium.

5 Ventricles The left ventricle collects the pure blood from the left atrium and delivers it to the aorta (main artery) from where it is pumped to the rest of the body. The aortic valve regulates this delivery. (Refer fig. 3) Unit 1: Normal Heart Anatomy Ventricles (Fig. 3) Pulmonary Arteries As part of the pulmonary circulation, pulmonary arteries carry the deoxygenated blood from the right ventricle to the lungs for oxygenation. (Refer fig. 4) Pulmonary Arteries (Fig. 4) Pulmonary Veins After oxygenation in the lungs, blood is brought back to the heart by pulmonary veins and delivered to the left atrium. (Refer fig. 5) Pulmonary Veins (Fig. 5) Aorta The Aorta, the largest artery in the body, collects blood pumped from the left ventricle to branch and deliver the oxygen rich blood to various organs and tissues in the human body. (Refer fig. 6) Aorta (Fig. 6)

Unit 1: Normal Heart Anatomy Carotid Artery Anatomy The right common carotid artery and the left common carotid artery, the two main arteries in the neck, branch off from the arch of the Aorta.

6 Unit 1: Normal Heart Anatomy Carotid Artery Anatomy The right common carotid artery and the left common carotid artery, the two main arteries in the neck, branch off from the arch of the Aorta. These arteries are responsible for supplying oxygen rich blood to the head. The carotid arteries can be located by feeling for a pulse under the jaw line on either side of the neck. These two arteries branch respectively into the right internal and right external artery and the left internal and left external artery. When these arteries become narrowed or blocked a stroke or cerebral vascular accident (CVA) can occur. Carotid Artery Anatomy (Refer fig. 7) (Fig. 7) Right Carotid Artery (Refer fig. 8) Right Carotid Artery (Fig. 8) Left Carotid Artery (Refer fig. 9) Left Carotid Artery (Fig. 9)

7 Unit 1: Normal Heart Anatomy Right Internal Artery (Refer fig. 10) Right Internal Artery (Fig. 10) Left Internal Artery (Refer fig. 11) Left Internal Artery (Fig. 11) Right External Artery (Refer fig. 12) Right External Artery (Fig. 12) Left External Artery (Refer fig. 13) Left External Artery (Fig. 13)

What is Carotid Artery Disease? Carotid Artery Disease is usually caused from atherosclerosis. Atherosclerosis is a condition in which fatty material is deposited along the walls of arteries.

Unit 2: Carotid Artery Disease (Fig. 14) (Refer fig. 14 & 15) (Fig. 15) When atherosclerosis occurs within the carotid arteries in the neck, the condition is referred to as Carotid Artery Disease.

8 What is Carotid Artery Disease? Carotid Artery Disease is usually caused from atherosclerosis. Atherosclerosis is a condition in which fatty material is deposited along the walls of arteries. This fatty material (often called plaque) thickens and hardens causing a narrowing of the artery and may eventually completely block blood flow within the arteries. Unit 2: Carotid Artery Disease (Fig. 14) (Refer fig. 14 & 15) (Fig. 15) When atherosclerosis occurs within the carotid arteries in the neck, the condition is referred to as Carotid Artery Disease. Carotid Artery Disease is a serious condition as it increases the risk of having a stroke three different ways. These include: Impaired blood flow: Severe narrowing of the carotid artery through accummulation of fatty deposits limits blood flow to the brain depriving brain cells of oxygen and nutrients leading to nerve cell death and stroke. Blood clot formation: If a blood clot forms it can become trapped in a narrowed carotid artery blocking blood flow and causing a stroke. Plaque blockage: If plaque breaks away from the inside of the artery and travels to a smaller vessel in the brain the plaque can cause a blockage impairing blood flow and causing a stroke. Risk Factors (Refer fig. View it in next page fig 16)

Unit 2: Risk Factors Risk factors for Corotid Artery Disease include the following: Carotid Coronary Artery Disease Family history Hypertension (High

Cigarette Smoking (Fig. 16) Stress Menopause Non-compliance with medicines to treat hypertension and high cholesterol. (Refer fig.

Unfortunately, a stroke, also called a cerebral vascular accident or CVA, may be the first sign of Coronary Artery Disease.

9 Unit 2: Risk Factors Risk factors for Corotid Artery Disease include the following: Carotid Coronary Artery Disease Family history Hypertension (High Blood Pressure) High Cholesterol or other fat levels in blood Inactive lifestyle-obesity/ overweight/ lack of exercise Diabetes (High blood sugar) Cigarette Smoking (Fig. 16) Stress Menopause Non-compliance with medicines to treat hypertension and high cholesterol. (Refer fig. 16) Signs and Symptoms Carotid Artery Disease does not usually cause symptoms in the early stages of its development. Unfortunately, a stroke, also called a cerebral vascular accident or CVA, may be the first sign of Coronary Artery Disease. There are, however, warning signs of a stroke that can occur called Transient Ischemic Attacks, or TIA s. The symptoms of TIA s are similar to a stroke but resolve in minutes or hours without the long-term effects associated with a CVA.

10 Unit 2: Carotid Coronary Artery Disease Signs and Symptoms Symptoms of a TIA include: Weakness, numbness, or tingling in an arm or leg on one side of the body Slurred speech Headache Vision loss in one eye Confusion Symptoms resolve within 24 hours Because the symptoms of a TIA and Stroke are similar it is important for a patient experiencing symptoms of a TIA to be evaluated by medical personnel. Early intervention is critical in the treatment of CVA and the prevention of further neurological damage. Diagnosis A Cardiologist should evaluate all cardiovascular conditions for proper diagnosis and treatment. Your Cardiologist will perform the following: Medical History Physical Examination If your doctor suspects Carotid Artery Disease they will usually perform the following test in the office: Carotid Duplex Ultrasound This is a painless, non-invasive test where a small ultrasound probe is placed over the carotid arteries in your neck. This test shows your physician blood flow within the arteries and how open the arteries are. Many times this test is all that is required for a diagnosis of Carotid Artery Disease. If the results are questionable, your doctor may order some of the following tests to confirm Carotid Artery Disease: CT Angiogram A special x-ray that uses computers to show cross sections of body tissues and organs allowing visualization of the blood flow in the carotid arteries. MRA Magnetic Resonance Angiography or MRA is a non-invasive test that provides a detailed picture of the arteries in the brain through the use of magnetic fields and radio waves.

Unit 2: Carotid Coronary Artery Disease Arteriography This test takes x-ray pictures of the carotid arteries after a dye is injected into the bloodstream.

11 Unit 2: Carotid Coronary Artery Disease Arteriography This test takes x-ray pictures of the carotid arteries after a dye is injected into the bloodstream. Cerebral Angiogram This test enables your doctor to take x-ray images of the inside of your blood vessels. This procedure is performed by a cardiologist and involves threading a tiny catheter through a small incision into a large artery, usually in your groin. Once the catheter reaches the site of the blood vessel to be viewed, a dye is injected and x- ray images are taken. Angiography enables your doctor to view how blood circulates in the vessels in specific areas of the body. Conservative Treatment Options Management of Carotid Artery Disease includes: Lifestyle Modifications Medications Lifestyle Modifications Healthy life choices will improve your overall health and can help you slow the progression of your cerebrovascular disease. Some heart healthy choices include: Healthy Diet Choices Eating a low fat, low salt, low cholesterol diet. (Refer fig. 17) Don't Smoke (Fig. 17) If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease as soon as you quit.

Exercise Increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of

18) Unit 2: Carotid Coronary Artery Disease (Fig. 18) Weight Loss Being overweight puts extra strain on your heart.

19) Diabetes Control Take your diabetic medications, check with your doctor for exercises and physical activity as well as nutrition

12 Exercise Increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of well-being. Always discuss with your doctor before beginning any new exercise program. (Refer fig. 18) Unit 2: Carotid Coronary Artery Disease (Fig. 18) Weight Loss Being overweight puts extra strain on your heart. Discuss weight loss options with your doctor and follow his advice. (Refer fig. 19) (Fig. 19) Diabetes Control Take your diabetic medications, check with your doctor for exercises and physical activity as well as nutrition advice. (Refer fig. 20) (Fig. 20) High Blood Pressure Control Keep blood pressure well controlled with medications, exercise and diet. Cholesterol Control Keep cholesterol within normal limits through diet, exercise and cholesterol lowering medications.

13 Unit 2: Carotid Coronary Artery Disease Medications Along with life style modification, medications may be needed to control symptoms and improve the heart health. More than one medication may be prescribed. Some common medications are listed below. Anticoagulants or Thrombolytic Agents These blood thinning medicines are given during a heart attack to break up a blood clot in a coronary artery in order to restore blood flow. Aspirin Aspirin reduces the tendency of small blood cells called platelets to stick together, which helps prevent the formation of a blood clot (thrombosis). Statins Statins are cholesterol-lowering medications to control lipid or fat levels in the blood.

Unit 2: 3: Carotid Coronary Artery Stenting Disease : Introduction If conservative treatment options are unsuccessful at treating Carotid Artery Disease and you are at risk of having a stroke or have

This procedure is major surgery involving general anesthesia and incisions along the neck.

14 Unit 2: 3: Carotid Coronary Artery Stenting Disease : Introduction If conservative treatment options are unsuccessful at treating Carotid Artery Disease and you are at risk of having a stroke or have a history of stroke, your Cardiologist may recommend a non-surgical procedure called. The standard surgical procedure for treating Carotid Artery Disease is a Carotid Endarterectomy. This procedure is major surgery involving general anesthesia and incisions along the neck. is a newer, minimally invasive procedure performed under local anesthesia through a tiny incision in the groin. The benefits and risks of both procedures are similar in the short term up to one year, however, due to the newness of Carotid Artery Stenting, long-term benefits and complications are uncertain and have not been established. may be indicated for patients who are at high risk of experiencing adverse events while undergoing a major surgery such as a Carotid Endarterectomy. It is important that you understand and discuss the benefits and risks for your particular situation with your doctor before deciding which procedure is best for you. How is it done? is performed by an Interventional Cardiologist in the Cardiac Catheterization Lab of the hospital under local anesthesia and IV sedation. You will be awake but relaxed and drowsy. During a procedure, the patient is placed lying on their back on an x-ray table. The catheter insertion area, the groin, is shaved, disinfected, and injected with a local anesthetic to numb the area. Your Cardiologist will perform an angiogram first to determine the extent and location of blockage within the carotid arteries prior to proceeding to an angioplasty with stenting. Your surgeon will make a tiny cut over the insertion site and insert a small tube called a sheath into a blood vessel in the groin. (Refer fig. 21 to 26) (Fig. 21) (Fig. 22)

Unit 2: 3: Carotid Coronary Artery Stenting Disease How is it done?

A special dye is then injected through the catheter and into the artery so x-ray pictures can be obtained showing the location and extent of the blockage.

Your cardiologist will now insert a guide wire through the catheter advancing it across the blockage to place the embolic protection device.

The embolic protection device greatly reduces the risk of stroke during the procedure.

15 Unit 2: 3: Carotid Coronary Artery Stenting Disease How is it done? A flexible tube called a catheter is then gently passed through the sheath into the vessel until the blockage is reached in the neck. A special dye is then injected through the catheter and into the artery so x-ray pictures can be obtained showing the location and extent of the blockage. Once the blockages are identified with the angiogram, the cardiologist can proceed with the procedure. Your cardiologist will now insert a guide wire through the catheter advancing it across the blockage to place the embolic protection device. This device can be a filter or a balloon that is used to trap any debris or emboli from escaping into the circulation during the procedure. The embolic protection device greatly reduces the risk of stroke during the procedure. The catheter with a deflated balloon on its end is then threaded over the guide wire into the blockage. The balloon is then inflated to push the plaque against the artery walls. This opens up the artery allowing increased blood flow through the artery to the head. Your cardiologist may deflate and inflate the balloon more than once within an artery to ensure the best result. (Fig. 23) (Fig. 24) (Fig. 25) (Refer fig. 21 to 26) (Fig. 26)

16 Unit 2: 3: Carotid Coronary Artery Stenting Disease How is it done? Next, the cardiologist will place a stent within the carotid artery. A stent is a wire mesh tube placed within the artery to help keep the artery open. The stent is placed over the deflated balloon at the tip of the catheter before inserting the catheter into the blockage. When the balloon is inflated, the stent is pushed in place against the artery wall. Some stents are coated with medicine to keep blood clots from forming or the artery from closing. Once your doctor is satisfied with the results, the balloon is deflated and the guide wire and catheter are withdrawn along with the embolic protection device. The stent remains in place within the artery. Pressure will be applied to the insertion site for 15 minutes followed by a tight pressure bandage to prevent bleeding. (Refer fig. 21 to 26) Post Operative Guidelines After the procedure you will be taken to the recovery room and be told to lie still for 6-8 hours to prevent bleeding from the puncture site. Recovery time varies. You may be discharged the same day or, depending upon your recovery, spend one or two nights in the hospital. Common post-operative guidelines following include the following: You will need someone to drive you home after you are released. You should not drive for 1-2 days after the procedure. Do not remove the dressing over the puncture site until instructed to do so. Keep the area clean and dry. Your surgeon may give you activity restrictions such as no heavy lifting for a few days to prevent bleeding from the insertion site. You may have soreness and bruising around the puncture site. Your doctor will prescribe blood-thinning medicines to prevent blood clots from forming around the stent. It is very important that you adhere to your prescribed medications to prevent blood clots from forming. Contact your doctor immediately if you have a fever, chills, redness, bleeding, irregular heart beat, chest pain, shortness of breath, weakness, or dizziness.

17 Unit 2: 3: Carotid Coronary Artery Stenting Disease Risks and Complications As with any medical procedure there are potential risks involved. The decision to proceed with the procedure is made because the advantages outweigh the potential disadvantages. It is important that you are informed of these risks before the procedure takes place. Most patients do not have complications after ; however complications can occur and depend on what type of procedure your doctor performs as well as the patient s health status. (i.e. obese, diabetic, smoker, etc.) Complications can be medical (general) or specific to. Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications Include: Allergic reaction to medications or dye Blood loss requiring transfusion with its low risk of disease transmission Heart attack, strokes, kidney failure, pneumonia, bladder infections Complications from insertion site such as infection or nerve damage Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death. Specific complications for include: Restenosis- Restenosis is the re-accumulation of plaque or scar tissue causing narrowing or blockage again of the carotid artery. Stroke- During the procedure plaque can break off and cause a blockage in a vessel. This risk is lessened with the use of the embolic protection device. Bleeding from the insertion site Infection Blood vessel damage from the catheter Kidney damage from dye used with angiogram Blood clots Stent moves from its placed location Complications can be medical (general) or specific to. Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications Include:

18 Unit 2: 3: Carotid Coronary Artery Angioplasty Stenting Disease Risk factors that can negatively affect adequate healing after surgery include: (Fig. 27)

19 Unit 3: Disclaimer Disclaimer Although every effort is made to educate you on Angioplasty and take control, there will be specific information that will not be discussed. Talk to your doctor or health care provider about any concerns you have about Angioplasty. You must not proceed until you are confident that you understand this procedure, particularly, the complications.

20 YOUR SURGERY DATE READ YOUR BOOK AND MATERIAL VIEW YOUR VIDEO /CD / DVD / WEBSITE PRE - HABILITATION ARRANGE FOR BLOOD MEDICAL CHECK UP ADVANCE MEDICAL DIRECTIVE PRE - ADMISSION TESTING FAMILY SUPPORT REVIEW Physician's Name : Physician's Signature: Date : Patient s Name : Patient s Signature: Date :

ANGIOPLASTY AND STENTING

ANGIOPLASTY AND STENTING What is angioplasty and stenting? During an angioplasty, your vascular surgeon inflates a small balloon inside a narrowed blood vessel. This balloon helps to widen your blood vessel