Section 3.33 Blood Clots Cardiovascular Surgeries

Specific Treatments / Therapies for Disease and Injury

• Thrombus, Embolism, and PVD• Cardiovascular Disease

– (Heart Disease)

• Orthopedic Diseases / Injuries– Osteoarthritis (Knees & Hips)– Tendon / ligament injuries

• Spinal Cord Injured Patients

Clot DisordersThrombi, Emboli

• Main concern associated with therapeutics is the development of pulmonary emboli.– Symptoms

• Chest pain and breathlessness, sometimes with fever. The person may cough up some blood.

• Right ventricular failure• Severe angina and sudden death can

result.

Pulmonary Emboli

Pulmonary Emboli

Pulmonary Emboli• Causes

– Any surgery or prolonged immobility– A fracture of a lower limb or the pelvis – Abdominal surgery– A long-haul flight in an aircraft– Any debilitating disease– An abnormal tendency for the blood to clot– Pregnancy and childbirth– Smoking– Excess estrogens

Pulmonary Emboli

• Prevention– Mobility / Exercise– Compression stockings– Anticoagulant drugs

• Treatment– Anticoagulant drugs– Surgical removal of clot– Vena caval filter insertion

Coronary Artery Disease (CAD) a.k.a.

Cardiovascular Disease (CVD)• Diagnosis

– Stress test• Ischemia causes abnormal repolarization of heart

(can be seen on ECG)

– Echocardiogram (ultrasound waves)• Stress - Echo

– Nuclear stress test (Thallium stress test)– Cardiac catheterization ("cath")

• AKA: coronary angiography• Invasive (Used for final evaluation / diagnosis)

Echocardiogram

•

Nuclear Stress Test Images

Normal

Abnormal

Ischemic Areas

Cardiac Catheterization• Under LOCAL anesthetic, guide wire &

catheter is inserted into femoral artery and is advanced into the aorta, L.V. of heart

• Contrast medium (dye) is injected into coronary arteries…produces image

• Measurements taken during procedure– Blood pressure within heart and arteries– Blood samples– Ventriculogram (LV function)– * Angiogram (coronary arteries)

Ventriculogram (LV function)

Cardiac Catheterization

*

*

Cardiac Catheterization• Risks

– Bleeding around the point of incision – Abnormal heartbeats (arrhythmias) – Allergic reaction to the dye – Infection – Blood clots*– Perforation of a blood vessel, or other damage to

the arteries – Heart attack– Stroke – Air embolism – Death

Cardiac CatheterizationNormal Cath Images

Right CA Left CA

Coronary Artery Disease (CAD)• Treatment

– Balloon angioplasty• Often done during Catheterization• May involve placement of stent

– Metal mesh sleeve to hold artery open

– Coronary Artery Bypass Graft (CABG)• Harvested vein used to “bypass” blocked

coronary artery• Very traumatic surgery, but has very high

success rate today• Bypass vein tend to become narrowed by

plaques faster than original arteries?

Balloon Angioplasty•Catheter with balloon placed at

the end is advanced into the artery where blockage is.

•Balloon is inflated; pressing plaque against artery walls. Opens passage for better blood flow.

•Stent is often placed and expanded to act as scaffold to hold artery open

Balloon Angioplasty

Coronary Stent

Coronary Stent

Coronary Stent

Stent Placement

Balloon Angioplasty

• Risk associated with B.A.–Heart Attack–Death–Emergency Bypass Surgery (CABG)

Coronary Artery Bypass Graft Surgery (CABG)

• World most expensive “Plumbing Job”– Approximately $45,000 (Sollano 2002)

• Harvested vein (saphenous vein) or artery (mammary artery) is sutured in place to “bypass” blocked artery.

• Heart has to be slowed / stopped. Blood is sent through a heart – lung machine.– “Beating Heart” bypasses are being done

more and more

• Takes 3 – 6 hours.

CABG

CABG

Physical Considerations for CABG Patients and Exercise

• Chest incision, sternum healing, and vein graft site.– Unable to lift >10 lbs. For several

weeks.

• Detraining is rapid….exercise soon and often.

• Often on medications that limit ability to exercise (I.E. Beta Blockers)

CABG: Risks

Developments In Cardiac Surgery• CABG with smaller incisions, thorascopes,

and done on beating heart (No Heart & Lung Machine)

• Use of radial artery for graft. (results have been more positive, better outcomes)

• Atherectomy, gene therapy (inhibits hyperplasia of intimal cells), & local radiation (shrink plaques on artery walls)

• Transmyocardial Laser Revascularization (TMLR): May not last for long periods of time: scarring / healing of channels