Angioplasty Care
A nonsurgical approach to opening coronary vessels narrowed by arteriosclerosis, percutaneous transluminal coronary angioplasty (PTCA) uses a balloon-tipped catheter that’s inserted into a narrowed coronary artery. This procedure, performed in the cardiac catheterization laboratory under local anesthesia, helps restore circulation to the heart, relieving pain caused by angina and myocardial ischemia.
A type of percutaneous coronary intervention, angioplasty, when it can be performed within 90 minutes of the patient’s arrival to the emergency department, is recommended by the American Heart Association as the treatment of choice for managing ST-elevation myocardial infarction (STEMI). When angioplasty is used to treat STEMI, it may be performed with or without stent placement. However, stent placement decreases the risk of target vessel revascularization and may reduce the risk of myocardial reinfarction (MI). Thus, stent placement has become routine during angioplasty in such patients.1,2
Cardiac catheterization usually accompanies PTCA to assess the stenosis and the efficacy of the angioplasty. Catheterization is used as a visual tool to direct the balloon-tipped catheter through the vessel’s area of stenosis. As the balloon is inflated, the plaque is compressed against the vessel wall, allowing coronary blood to flow more freely. (See Performing PTCA.)
PTCA provides an alternative for patients who are poor surgical risks because of chronic medical problems. It’s also useful for patients who have total coronary occlusion, unstable angina, and plaque buildup in several areas and for those with poor left ventricular function. After angioplasty, it’s important to monitor the patient closely for signs and symptoms of coronary spasm, MI, and bleeding at the insertion site.
Equipment
Antiseptic solution (chlorhexidine-based solution is preferred) ▪ local anesthetic ▪ IV solution as ordered and tubing ▪ electrocardiogram (ECG) monitor and electrodes ▪ oxygen and oxygen delivery system ▪ clippers ▪ sedative ▪ contrast medium ▪ emergency medications ▪ emergency equipment, including a defibrillator, a handheld resuscitation bag, and intubation equipment ▪ heparin for injection ▪ introducer kit for PTCA catheter ▪ eye protection ▪ gloves ▪ sterile gown, gloves, and drapes ▪ surgical cap, mask, and eye protection ▪ Optional: nitroglycerin, pulmonary artery (PA) catheter, transparent dressing.
Implementation
Preprocedure Care
Confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.3
Explain the procedure to the patient and his family to reduce the patient’s fear and promote cooperation.
Inform the patient that the procedure lasts from 1 to 4 hours and that he may feel some discomfort from lying on a hard table for that long.
Tell him that a catheter will be inserted into an artery or a vein in his groin and that he may feel pressure as the catheter moves along the vessel.
Reassure him that although he’ll be awake during the procedure, he’ll be given a sedative. Explain that the doctor or nurse will ask him how he’s feeling and that he should tell them if he experiences any chest pain.
Explain that the doctor will inject a contrast medium to outline the lesion’s location. Warn the patient that he may feel a hot, flushing sensation or transient nausea during the injection.
Conduct a preprocedure verification process to make sure that all relevant documentation, related information, and equipment are available and correctly identified to the patient’s identifiers.4
Check the patient’s history for allergies; if he has had allergic reactions to shellfish, iodine, or contrast media, notify the doctor.
Make sure that informed consent has been obtained and is documented in the patient’s medical record.5
Restrict food and fluids for at least 6 hours before the procedure, or as ordered.
Ensure that the results of coagulation studies, complete blood count, serum electrolyte studies, and blood typing and crossmatching are available.
Administer antiplatelet drugs and antithrombotic drugs as ordered, following safe medication administration practices.2,9
Insert an IV catheter in case emergency medications are required. (See “IV catheter insertion and removal,” page 421.)
Clip hair from the insertion site (groin or brachial area).10
Clean the area of skin at the insertion site with antiseptic solution.
Give the patient a sedative as ordered, following safe medication administration practices.
Obtain baseline vital signs and assess peripheral pulses in all extremities.
Communicate information about the patient’s history, condition, and care to the nurse who will care for the patient during PTCA and then give her the opportunity to ask questions. Handoff communication between caregivers promotes patient safety and prevents errors.
Document your preparation of the patient.11
Performing PTCA
Percutaneous transluminal coronary angioplasty (PTCA) is a procedure that opens an occluded coronary artery without opening the chest. It’s performed in the cardiac catheterization laboratory after coronary angiography confirms the presence and location of the occlusion. When the occlusion is located, the doctor threads a guide catheter through the patient’s femoral artery and into the coronary artery under fluoroscopic guidance.
When the guide catheter’s position at the occlusion site is confirmed by angiography, the doctor carefully introduces into the catheter a double-lumen balloon that’s smaller than the catheter lumen. He then directs the balloon through the lesion, where a marked pressure gradient will be obvious. The doctor alternately inflates and deflates the balloon until an angiogram verifies successful arterial dilation and the pressure gradient has decreased.
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