Directional coronary atherectomy is a catheter intervention that allows us to shave out specific types of narrowing in the coronary artery. This procedure may be preferable to balloon angioplasty.
Some of the factors that determine angioplasty versus atherectomy are the location of the blockage, the shape of the blockage, the size of the artery and whether clots are present in the artery. All of these considerations are up to the discretion of the interventional cardiologist.
When it is determined that directional coronary atherectomy is appropriate, the pre-existing catheter in the femoral artery needs to be exchanged for a larger catheter. This is due to the greater bulkiness of the directional coronary atherectomy device. A guiding catheter which allows us to place the guide wire and the directional coronary atherectomy device across the lesion is placed in the aorta at the opening of the coronary artery. Once this guiding catheter is in place, an appropriately sized atherectomy device is chosen. Often, if the narrowing is extremely tight, it may need to be predilated with a small angioplasty balloon in order to allow easier passage of the atherectomy device across the narrowing. After this, the atherectomy device is then placed across the narrowing.
The atherectomy device is a large balloon catheter. However, the balloon is only wrapped around a portion of the circumference of the device. It allows for placement of a window in the metal housing on the side of the catheter and this window is then pushed against the plaque by the balloon and a cutting piston is then advanced through the device in order to shave off the plaque tissue that has been placed in the window. This plaque tissue is then pushed into the nose cone of the device and it will be removed later during the procedure. Typically, during this procedure, your doctor will take four cuts at a time before removing the device from the coronary artery and examining the result. On occasion, your doctor will have to again place the device across the narrowing and take multiple cuts. Your doctor may take anywhere from four to more than twenty cuts in a given blockage in order to obtain a good angiographic result. The amount of tissue removed at the end of the procedure can be variable and is dependent upon the amount of plaque present at the site of the narrowing. At the end of the procedure, occasionally a balloon may need to be placed in order to smooth out the angiographic result, although this occurs less frequently. You are then sent back to your room where a period of bedrest is required. The sheath will be removed from your groin after the specific amount of time the cardiologist orders.
Prior to your discharge, you should have received information on the following:
Medication: Upon discharge your nurse and doctor will give you an explanation of all your medication. These instructions will include the medication name, dosage, schedule, and possible side effects.
Diet: You should follow a low cholesterol diet. Instructions regarding this diet will be given by the dietitian prior to your discharge.
Risk Factors: Your risk factors for the development of arteriosclerosis have been discussed. You should be aware of these risk factors and be making plans to modify your lifestyle to reduce these risk factors.
Common Activities
Bathing
Showers are usually allowed within 24 hours after you are allowed out of bed. Wash normally, with any kind of soap and water but do not apply unusual pressure at the site of the catheter insertion. Pat dry instead of rubbing the skin dry around the site. No baths for three days because the bath water may be a media for infection into the blood stream.
Site Care
A small bandage may or may not be applied; if it is, it can be removed; bruising will gradually fade within one to two weeks; a hematoma (collection of blood in the tissue) may be painful to touch but should also reduce in size and tenderness within one to two weeks. If increased bruising, swelling or infection is noted, your doctor should be notified immediately. Also, watch for any signs of infection such as drainage, warmth, redness or increased temperature from the site.
Activity: Most patients who have had angioplasty, atherectomy, or stent can return to their daily routine within three days to one week unless they have heart damage (heart attacks). Patients with heart damage may be told to resume activity more slowly. Check with your doctor. All patients should avoid lifting anything greater than 5-10 pounds the first few days home.
Driving: Driving can be resumed within a few days to one week unless you have been told you had heart damage (heart attack). Patients with heart damage should check with their cardiologist before driving. All patients should arrange to have someone drive them home from the hospital.
Working: Ask your doctor when you will be able to return to work. The nature of your occupation plus your progress will determine this. Patients may return within several days to several weeks.
Sex: If you are able to climb a flight of stairs comfortably, you can resume sexual activity.
Exercise: The day after you go home, begin walking 2-3 times per day. Start out walking about the same amount you did in the hospital. Increase the distance based on tolerance. Extreme shortness of breath, dizziness, extreme fatigue, or chest discomfort are all signs that you are doing more than your heart is ready for. If these occur, stop and rest. Next time you walk, slow down and/or cut back on the distance. If these symptoms persist after resting, notify your physician.
Office Visit: Follow-up with your physician in one to two weeks after discharge from the hospital. A follow-up treadmill test will be performed to determine the success of the procedure and the current status of your physical and cardiac condition. Then you will be required to enter a Cardiac Rehab program located closest to your home as part of your recovery program.