Very High Risk Surgical Patient Angioplasty
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- / Dr. Ravi Gupta
Very High Risk Surgical Patient Angioplasty
Pre-Procedure Assessment
Comprehensive Evaluation
Medical History: Detailed review of the patient’s medical history, including comorbid conditions (e.g., diabetes, chronic kidney disease, COPD).
Current Medications: Assessment of all current medications, including antiplatelet agents, anticoagulants, and drugs for comorbid conditions.
Functional Status: Evaluation of the patient’s functional capacity and frailty.
Diagnostic Tests
Electrocardiogram (ECG): To assess baseline cardiac function and detect any existing arrhythmias.
Echocardiography: To evaluate left ventricular function, valve status, and overall cardiac anatomy.
Stress Testing: Non-invasive stress tests, if the patient’s condition allows, to assess ischemia.
Coronary Angiography: To visualize coronary anatomy and determine the extent and severity of disease.
Procedural Considerations
Procedure Planning
Access Site: Consider radial access to minimize bleeding complications, though femoral access may be necessary depending on the patient’s anatomy and procedural requirements.
Adjunctive Imaging: Utilize intravascular imaging (IVUS or OCT) to guide precise stent placement and optimize outcomes.
Hemodynamic Support: Plan for potential use of hemodynamic support devices such as an intra-aortic balloon pump (IABP) or percutaneous ventricular assist devices (Impella) in case of compromised cardiac function.
Pharmacological Management:
Antiplatelet Therapy: Administer dual antiplatelet therapy (aspirin and a P2Y12 inhibitor) while considering the patient’s bleeding risk.
Anticoagulation: Use appropriate anticoagulation during the procedure, typically with unfractionated heparin or bivalirudin, based on renal function and bleeding risk.
During the Procedure
Monitoring and Support:
Continuous hemodynamic monitoring and readiness to address any complications promptly.
Use of contrast-sparing techniques to reduce the risk of contrast-induced nephropathy in patients with impaired renal function.
Interventional Techniques:
Lesion Preparation: Adequate lesion preparation with techniques such as balloon pre-dilation, atherectomy, or cutting balloons for heavily calcified lesions.
Stenting: Careful selection and deployment of drug-eluting stents (DES) to ensure optimal vessel patency and reduce the risk of restenosis.
Post-Procedure Care
Immediate Post-Procedure Monitoring:
Intensive monitoring in a cardiac care unit (CCU) or intensive care unit (ICU) to manage potential complications such as bleeding, arrhythmias, or myocardial infarction.
Pharmacotherapy
Continued dual antiplatelet therapy, tailored to the patient’s risk profile and bleeding risk.
Optimization of other cardiovascular medications, including beta-blockers, ACE inhibitors, or statins.
Performing angioplasty in very high-risk surgical patients requires a comprehensive and individualized approach to maximize safety and effectiveness. This involves thorough pre-procedure assessment, careful procedural planning, multidisciplinary collaboration, and vigilant post-procedure care.