Stenting of the heart: description of the operation, its dignity, rehabilitation

From this article you will learn: what is this operation - the stenting of the heart vessels, why it is considered one of the best methods of treatment of different forms of ischemic disease, the peculiarities of its conduct.

Contents of the article:

Description of the operation
The real advantages of the stenting method
In what cases is coronary stenting
Contraindications
How is surgery performed
After the operation
Stenting results and prognosis

Stenting of the coronary vessels of the heart is a minimally invasive endovascular( intravascular) operationon the arteries, blood supplying the heart, which consists in the expansion of their narrowed and corked areas by installing into a hollowlt; / RTI & gt;

Endovascular surgeons, cardiosurgeons and vascular surgeons are engaged in such surgical interventions in specialized centers of endovascular cardiosurgery.

Description of operation

Atherosclerosis of the coronary arteries, manifested by the formation in the lumen of these vessels of cholesterol plaques - a typical causal mechanism of the development of coronary heart disease. These plaques have the appearance of protrusions and tubercles in which inflammation, scarring, destruction of the inner layer of the vessel and the formation of blood clots occur. Such pathological changes reduce the vascular clearance, partially or completely clog the artery, reducing the flow of blood to the myocardium. This threatens his ischemia( oxygen starvation) or a heart attack( necrosis).

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The meaning of heart vessel stenting is to restore the lumen of the coronary arteries in the areas of constriction with atherosclerotic plaques with the help of special expanders - coronary stents. Thus, it is possible to reliably and fully restore normal blood circulation in the heart.

Stenting does not relieve atherosclerosis, but only for a time( several years) eliminates its manifestations, symptoms and the negative consequences of coronary disease.

Features of the procedure of coronary stenting:

This operation is endovascular - all manipulations are performed exclusively inside the lumen of the vessels, without cuts of the skin and violation of their integrity in the affected areas.
The lumen of the clogged artery is not restored by removing atherosclerotic plaque, but with the help of a stent - a thin metal vascular prosthesis in the form of a mesh duct.
The task of a stent inserted into a narrowed section of the artery is to press atherosclerotic plaques into the walls of the vessel and push them apart. This action allows you to expand the lumen, and the stent itself is so strong that it acts as a framework that stably holds it.
In one operation, as many stents can be installed as needed depending on the number of narrowed sections( from one to three or four).
Stenting requires the patient to be given radiopaque substances( preparations) filled with coronary vessels. To register their image, as well as control the progress of contrast, high-precision X-ray equipment is used.

More detailed information about

stents The stent installed in the lumen of the narrowed coronary artery should become a reliable internal skeleton that will not allow the vessel to re-shrink. But such a requirement, presented to him, is not the only one.

Any implant introduced into the body is foreign to tissues. Therefore, avoiding the reaction of rejection is difficult to avoid. But modern coronary stents are so well thought out and constructed that they do not cause any additional changes.

The main characteristics of the new generation stents are:

Are made of a metal alloy of cobalt and chromium. The first provides good tissue susceptibility, the second - strength.
In appearance it resembles a tube about 1 cm long, from 2.5 to 5-6 mm in diameter, whose walls have the form of a grid.
The mesh structure allows you to change the diameter of the stent from the minimum that you need during the conduct to the occlusion site, to the maximum that you need to expand the narrowed section.
Covered with special substances that block the coagulability of blood. They are gradually released, preventing the reaction of the clotting system and the formation of thrombi on the stent itself.

Old stent samples have significant drawbacks, the main one of which is the lack of anticoagulant coating. This is one of the main reasons for unsuccessful stenting due to their clogging with blood clots.

The real merits of the

method Stenting the heart arteries is not the only way to restore coronary blood flow. If this were so, the problem of ischemic disease would have been solved. But there are such advantages that allow stenting to be considered a truly effective and safe method of treatment.

Competing methods - aortocoronary shunting and drug therapy. Each of the methods has some advantages or disadvantages. None of them should be used according to the template principle, but individually compared with the features of the disease course in a particular patient.

The table shows the comparative characteristics of surgical techniques in order to identify the real benefits of coronary stenting.

Evaluation criterion

Staging	Shunt operation
Scope of operation	Minimal operation is considered to be a very invasive	Large in scope and complexity intervention
Duration	1 to 3 hours	3 to 9 hours
Cardiac arrest	Manipulation is performed on a working heart	B 60-70% need to stop the heart
Incision	Do not need	The chest is broken
Narcosis	Local anesthesia, less often superficial anesthesia	Deepcomponent narcosis
Recovery	Days-weeks	Weeks-months
Execution in acute cases	Possible treatment of infarction in acute period	Problematic due to severity of operation
Work with small arteries	Possible with vessel diameter from 3 mm or more	Problematic or notpossible
Circulatory recovery	For several years	Years-decade

As can be seen from the table, the stenting of the heart vessels is really a big breakthrough in modern medicinein the treatment of disorders of the coronary circulation. The method allows for a short time without much harm and risk to the body for a long time to restore the full blood supply of the myocardium.

In which cases coronary stenting is indicated

Despite all the advantages of stenting of the coronary vessels of the heart, it is not performed by all patients with coronary heart disease, but only to those to whom it will bring the most positive result in comparison with other methods. The main indications for the operation are:

Chronic forms of ischemic disease due to atherosclerotic plaques that cover the lumen of the arteries by more than 50%.
Frequent attacks of angina pectoris, especially if it provokes minor physical exertion.
Threat of myocardial infarction and acute coronary syndrome - pre-infarction.
The first 6 hours of a large or small myocardial infarction with a relatively stable general condition of the patient.
Reconstructive stenosis( occlusion of lumen) of the coronary arteries after balloon angioplasty, stenting and coronary artery bypass grafting.

Of all the indications of greatest interest are acute violations of coronary circulation - acute coronary syndrome and a heart attack. This is due to much better results of treatment compared with drug therapy( by 70-80%), if the intervention is performed within 6 hours of the onset of severe pain behind the sternum.

Contraindications

In some cases, patients who need coronary stenting, it can not be performed because of contraindications. These include:

Unstable or severe general condition of the patient - impaired consciousness, persistent drop in blood pressure, shock, severe failure of internal organs( hepatic, renal, respiratory).
Allergy to iodine preparations;
Diseases and conditions accompanied by a marked decrease in blood clotting( drug overdose, hemophilia, various coagulopathies).
Common, extended( more than 1-2 cm) and multiple atherosclerotic narrowing located in one or more of the arteries of the heart.
Lesion of arteries of small caliber with a diameter of less than 3 mm.
The presence of malignant tumors recognized as incurable.

The majority of contraindications are relative, since either they are temporary if there is a possibility of their complete or partial elimination, or they may not be taken into account if the patient insists on the operation.

Stenting can not be carried out under any circumstances, if the patient has an allergic reaction to iodine and preparations based on it.

How surgical intervention is performed

Preoperative preparation of

The minimum volume of preparations for stenting of the heart vessels is shown when it is performed urgently. In this case, there is no time for an extended examination. Performed:

general and blood coagulation analysis( coagulogram);
biochemical blood test for the level of AlAT, ASAT, creatine phosphokinase, troponins;
electrocardiography( ECG);
radiography of the lungs.

In especially urgent cases( about 5 hours after the onset of an infarct), physically healthy young patients are taken for analysis, and the operation is performed without waiting for results. If the stenting is performed in a planned manner, all patients are fully fully examined.

Procedure of operation

Coronary heart vessel stenting is performed in a special operating room under full sterility conditions using high-precision equipment and X-rays. The main instruments of the operating surgeon are probes and catheters-manipulators 2-3 mm thick, about 1 meter long. Consistently perform:

Local anesthesia - pitting with Novocaine or another anesthetic of one of the inguinal-femoral areas( right or left).
Puncture-puncture of the femoral artery with the introduction of a catheter manipulator into the lumen.
As the catheter moves up the aorta towards the heart, an iodine preparation( Triambrast, Verografine) is injected, which is captured by X-rays. This action is necessary so that the surgeon can contrast the vessels and control where the catheter is. To do this, X-rays are passed through the patient through the patient, and the image is displayed on a digital monitor.
Coronary angiography is the filling of the heart vessels with contrast. Only after its completion can determine the state of the arteries, the possibility and volume of stenting.
Stent placement in the narrowed section - at the end of the manipulator catheter there is a balloon that, by inflation with air or liquid, expands the stent and artery to the desired diameter.

Possible complications of

Early postoperative and complications during surgery occur in 3-5%:

hematoma( haemorrhage) on the thigh;
damage to the heart vessels;
bleeding;
disorders of cerebral and renal circulation;
thrombosis( blockage of blood clots) stent.

After operation

In the first day patients who underwent stenting of the heart vessels should comply with bed rest, but within 3-4 days they can be discharged home. In general, life after surgery for compliance with treatment recommendations does not differ from that before its implementation. On how fully the requirements will be met, the length of patency of the vessels depends.

Strict Diet

Categorical rejection of fatty foods of animal origin and digestible carbohydrates, foods high in cholesterol, and salt. Their replacement for vegetables, fruits, dietary meats, vegetable oils, fish and other sources of omega-3 reliably stops the progression of atherosclerosis.

Gentle mode of loads

In the first week, any physical activity is contraindicated, except walking on level ground. In the future, their volume is gradually expanding in such a way that up to 4-6 weeks a person can start the usual activities. Heavy physical work, work at night and psychoemotional stress are contraindicated for life. Special exercises and exercise therapy help to recover faster and more fully.

Obligatory taking of medications and examinations

Monitoring of the patient's condition is carried out using:

ECG, including stress tests after 2 weeks;
studies of coagulability and lipid spectrum of blood;
coronary angiography( in the planned order only after a year);
blood clotting studies.

Lifetime medications are indicated:

Anticoagulants for blood thinning - preferably Clopidogrel( Plavix, Plagril, Trombone) or Warfarin, in the extreme case of Acetylsalicylic acid( Cardiomagnol, Lospirin, Magnikor).
Statitnov for the prevention of atherosclerosis - Atoris, Atorvastatin.
Beta-blockers and nitrates - only in those cases if there is a need( attacks of pain in the heart, frequent palpitations, high blood pressure).

Stenting result and forecast

Stenting restores the blood circulation of the heart, relieving the painful symptoms and the threat of a heart attack, but not from the root cause of their appearance - ischemic disease and atherosclerosis. No expert can predict the life expectancy of a patient after surgery. But the prognosis is 90-95% good - on average, the stent provides a patency of the coronary artery more than 5 years( maximum terms - 10-15 years, minimal - several days).

In 50-60%, the result of stenting is the disappearance of symptoms or residual manifestations of ischemic heart disease. The remaining 40-50% show a different degree of improvement in well-being. The longer the life of the stent, the higher the coagulability of the blood and the stronger the atherosclerotic process, the higher the probability of its clogging.

Remember, life is short, but beautiful, and coronary stenting is a sparing operation, restoring sick people the opportunity to live longer and as fully as possible!