post PTCA care

PTCA abbr. percutaneous transluminal coronary angioplasty PTCA

http://heartlandcardio.com/Portals/15/Skins/HCC/documents/Care%20of%20The%20Post%20PICA%20(Stent).ppt#266,11,Retroperitoneal Hematoma 

Initial Evaluation of PCI Patient in Office

•Check for Vascular Complications
–Hematoma
–Retroperitoneal Bleed
–Pseudoaneurysm
 
Vascular Complications
 
•Insertion of vascular sheaths may produce groin or retroperitoneal hematomas
•Groin hematoma presents with localized pain; lower extremity neurological symptoms are due to compression of the femoral nerve
•Palpation of localized swelling or tenderness in the area, or loss of sensory or motor function is highly suggestive of a hematoma
•Rates of major bleeding are decreasing (0.7% to 1.7%) 
 
Retroperitoneal Hematoma
 
•Low incidence (0.15% to 0.44%)
•Should be suspected in patients with unexplained hypotension and/or marked decrease in Hct
•Pts may experience flank, abdominal or back pain-
–Note: absence of these symptoms does not exclude this condition 
•Diagnosis established by CT
Most treated conservatively; only 16% require surgery
 
Pseudoaneurysm (PSA) 
•Communication between femoral artery and overlying fibromuscular tissue, resulting in a blood filled cavity
•Incidence ranges between 0.5% to 6.3%
Groin tenderness, a palpable pulsatile mass and/or new bruit in groin should prompt examination by Doppler flow imaging
•Most large PSA can be treated by US guided compression, US guided thrombin injection, or surgical repair
•New technology to treat PSA is percutaneous PTFE covered stent graft
 
 
Predictors of Late Stent Thrombosis 
Thienopyridine Discontinuation <6 months
Insulin Treated Diabetes
•Left Main Stenting
Smoking
•Lesion Length >28mm
Multiple Stents
•Moderate to Severe Lesion Calcification 
•Reference Vessel Diameter ❤ mm
•Ostial lesions
•Bifurcations
Low EF
Renal Failure
•Suboptimal Stent Result
•Platelet Nonresponsiveness
 
Oral Antiplatelet Agents Post PCI (Stenting) 
•Aspirin
•Thienopyridines
–Ticlopidine
–Clopidogrel
–Prasugrel
 
Ticlopidine 
•Initial Oral Thienopyridine
1% Risk of Severe Neutropenia
•Need CBC Monitoring
Rare TTP
Use in Patients Unable to Take Clopidogrel
•Full Antiplatelet Action Takes Several Days 
Clopidogrel 
Most Commonly Used Thienopyridine in U.S.
Onset of Full Effect within Hours of a Loading Dose
•Indicated in Patients After NSTEMI, U.A., STEMI 
Prasugrel 
•Newest Thienopyridine
•Triton TIMI-38   Trial—PCI
–13,680 Patients Randomized to Clopidogrel vs. Prasugrel
CV Death, MI, Stroke were Significantly Reduced in Prasugrel Group (9.9% vs. 12.1%)
Reduced Stent Thrombosis (2.4% vs. 1.1%)
•Major & Minor Bleeding was Significantly Increased in Prasugrel Group
•Not FDA Approved yet
 
Noncardiac Surgery Post PCI 
•Defer Elective Surgery for 1 Year
•If Surgery Needed After 3-6 months continue Low Dose Aspirin Periop. And Resume Clopidogrel Postop
(Refer to link above for alogarithm)
 
 
Antithrombin Rx 
•If a Patient needs Warfarin (AF, valve etc.) and has a Stent Implanted, then ASA + Clopidogrel + Warfarin are needed
1.Little Data on this Topic
2.? Increased Risk of Bleeding
3.Recent Registry Data Showed no Increased Death or Bleed 6 months Post Stent
4.Try and Keep INR Lower ~2.0
5.Consider BMS
6.Each Clinical Situation Will Dictated How Aggressively to Anticoagulate
 
 
Risk Factors for Restenosis
•Clinical:
Diabetes Mellitus
Chronic Renal Failure (Dialysis)
Unstable Onset Angina
Recent Onset Angina
•Anatomical:
Saphenous Vein Graft (Aorto-osteal and body)
Proximal left anterior descending artery
Long Lesion
Chronic Total Occlusions
Restenotic Lesion
Collateralized Distal Vessel
Multiple Lesions
? Smaller Diameter Vessels
•Procedural:
High Residual Stenosis
? Failure to Normalize Flow Reserve 
 
Restenosis 
•Occurs over 1 to 8 months post PCI
•Presenting symptoms include
exertional angina (25% to 85%)
unstable angina (11 to 41%)
 
 
Evaluation for Restenosis
 
•Prognosis for asymptomatic or “silent restenosis” is generally favorable
•Routine periodic monitoring is not beneficial, indicated or recommended*
–MI (1 to 6%)
plus more on lifestyle modification etc… refer to linkk!
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