【Local Medical】Coronary angioplasty with multiple lesions and complex coronary artery disease to save the heart

Written by ◆Chen Qiulei and compiled by ◆Liang Yingxiu

Treatments for coronary heart disease include medications, angioplasty, or heart bypass surgery.

When multiple lesions occur in the coronary arteries, complex coronary angioplasty may be necessary if certain conditions are met.

Most patients experience relief from chest pain, dyspnea and other symptoms after surgery, and have a chance to improve their heart function, and gradually return to normal life.

(Kuala Lumpur News) I believe that the general public is no stranger to coronary artery disease. By definition, coronary artery disease can also be called coronary heart disease, which is one of the diseases we are familiar with as heart disease.

The heart is divided into left and right sides. There are also two left and right coronary arteries, namely the left coronary artery, which is further divided into the left anterior descending artery, the left circumflex artery and the right coronary artery. If the blockage occurs in the coronary arteries of the heart, it is called coronary heart disease.

The left main coronary artery supplies blood to the left side of the heart muscle and usually covers a larger area of ​​the heart muscle than the right coronary artery.

Cholesterol accumulation leads to clogged arteries

Consultant cardiologist Dr Jayakhanthan Kolanthai Velu pointed out that many medical studies have shown that obstruction is mainly caused by the accumulation of cholesterol over time. This accumulated cholesterol sticks to the artery walls for years. Heart failure occurs when the fibrous cap ruptures and forms blood clots. At this time, the artery is 100% blocked, but the blood clot is soft and the condition is acute, making it easier to deal with.

“Sometimes a blockage does not necessarily lead to a heart attack. However, when the condition escalates to a severe level, the patient may begin to experience chest pain or angina.”

“High cholesterol causes fat deposits in blood vessels. Its formation is closely related to our daily habits and health, such as diabetes, high blood pressure, smoking, drinking, etc. People have always believed that diseases are a ‘patent’ for the elderly, but In recent years, we have found that people suffering from such diseases tend to become younger.”

As for the reason, it is mostly due to poor lifestyle, which causes many people to suffer from diseases such as diabetes and high blood pressure at a young age. Doctors have not ruled out that a family gene may be involved.

He said that treatments for coronary heart disease include drug therapy, angioplasty or percutaneous coronary intervention (PCI), cardiac bypass surgery (CABG), etc.

“However, there are several types of coronary artery disease. For example, the obstruction point does not only appear in one or two places, but may occur in multiple places, that is, multi-vessel disease; some obstruction points involve the aorta. ; Due to long-term blockage, blockage and hardening, etc.”

The treatment process for branch blockage is complicated

In addition, there is not just one artery, but some arteries branch out into larger branches. When these branches are blocked, we also need to treat these diseased branches, and the entire treatment process becomes more complicated.

He said, taking the left main coronary artery as an example. The left coronary artery has two bifurcation points. If blockage occurs, we need to perform bifurcation stenting, which means implanting stents in the left main coronary artery and side branches simultaneously. This bifurcation point is the most difficult part of the surgery.

Generally, the number of blood vessel blockage points and the points of blockage are used to determine the root cause treatment method suitable for the patient. How to define a complex coronary angioplasty?

He said that this aspect is divided into five parts, including: 1. Involving multiple branches, thus requiring the implantation of multiple stents; 2. Involving the left aorta; 3. Additional rotational atherectomy (RA), That is to grind and remove the hardened calcium plaque adhering to the blood vessel wall. After the blood vessel is opened, a stent is implanted; 4. Age and physical condition, including the strength of the heart and the presence of other diseases; 5. Patients with chronic total obstruction (Chronic Total Occlusion, CTO), its condition is 100% blocked and occurs for a long time. Doctors must use some special instruments and equipment to treat such patients, which makes treatment more difficult.

“When patients with weak heart function undergo complex coronary heart disease treatment operations,

Whether the left aorta is blocked or 100% blocked,

They all require special equipment to support the heart’s operation during surgery.

That is, Intra-Aortic Balloon Pump (IABP)

and temporary artificial heart pump,

We also call it Impella. “

Both are mechanical circulatory support devices (MCS).

The balloon dilatation pressure pump inflates and deflates through the heart’s beat,

Increases blood flow to the heart and reduces left ventricular load;

It is said to be the smallest in the world.

The function of a temporary artificial heart pump is to relieve pressure on the heart, especially to maintain blood pressure and provide blood flow support.

Intravascular ultrasound to view arteries

As for how to successfully carry out complex coronary angioplasty surgery, Jaya Ganden said that the instruments, tools and execution points to be used depend on the obstruction and the branches that need to be treated.

“Generally, there are two points for surgery, one is through the pulse point of the wrist, and the other is the groin. Sometimes both sides can be used, depending on the patient’s needs. The choice of large and small catheters is also determined by the disease condition or the patient’s physical endurance. , like some people’s hands are not suitable for implanting catheters, so they turn to the groin. The medical auxiliary devices mentioned above also implant catheters through the groin.”

For example, when treating a branch obstruction problem that requires the implantation of two balloons or two stents, only larger catheters can accommodate multiple medical implants.

In addition to using the above-mentioned devices, the surgeon will also use intravascular ultrasound (IVUS) before and after surgery to examine the internal condition of the artery through ultrasound-guided imaging to achieve durable, long-lasting and safe treatment. Post curative effect.

The plan will be decided based on the patient’s condition. If the arterial obstruction is severe, CABG will be performed.

Patients have different conditions and different treatment methods. As a doctor, it is necessary for patients to know what medical options are suitable for them and clearly understand the pros and cons of each course of treatment.

Jayaganden emphasized that if a patient faces multiple blockages in blood vessels, he will usually decide what treatment to do based on the patient’s condition, that is, the current condition, whether there are other diseases, age, and heart function.

In his opinion, complex coronary angioplasty is appropriate for patients with chronic total occlusion of coronary arteries and low cardiac function. However, this is not the case for some patients. If the obstruction is very severe, CABG can be performed.

Medication alone is not the best option

In addition to the above, the patient’s symptoms are also one of their considerations. For example, chest pain, difficulty breathing, etc.; some patients have no symptoms despite multiple obstructions. So when they mention the need for complex coronary angioplasty, which means the aorta is involved and multiple stents may need to be implanted, they will generally recommend CABG first. If the patient refuses, complex coronary angioplasty is performed.

“Some patients refuse any form of surgical treatment, so they can only temporarily rely on drugs to stabilize their condition. I usually prescribe medication to the patient first and observe it for two weeks or a month. Some patients recover after taking a large amount of medication in a short period of time. He returned to the hospital within a day and complained to me that the chest pain still persisted. I immediately formulated the next treatment plan. During the medication period, I will slowly convince them to perform corresponding surgical treatment.”

There are always risks in any surgery. For those with weak heart function, complex coronary surgery is slightly higher than ordinary surgery. Although the risk is only slightly elevated, there is no denying that the risk is there. He can understand that some people don’t want to take this risk, and they should understand the relevant information before making a decision.

It must be mentioned that drug treatment alone is not the best option. Taking drugs cannot clear the blockage of blood vessels at all. It can only reduce the chance of the old disease worsening or the new blockage increasing. Up to 90% of patients with severe blockage have stabilized their condition through drug treatment, but the blood vessel blockage has not improved.

Surgery should not take too long

Performing complex surgeries is challenging. As a professional surgeon, you must be fully prepared. Firstly, you must have sufficient knowledge and skills. Secondly, you must prepare sufficient medical instruments, equipment, any auxiliary devices, etc. The two are complementary to each other and cannot exist without the other.

Patient safety is an important consideration for physicians. The operation should not take too long and avoid exposing the patient to radiation or contrast media for a long time. Especially for kidney patients, too much contrast media should not be used. For patients with special circumstances, if the blockage occurs in multiple places, they may need multiple surgeries.

Is it possible to relapse after surgery? There are several main factors that will affect the results. First, the patient’s preoperative condition, including whether the condition is properly controlled, the severity of the disease in the early stage, etc.; second, during the operation, appropriate instruments and equipment are used to ensure that it is completed with excellent technology. Surgery; 3. Postoperative care, the patient follows the instructions, takes medication, and changes his lifestyle.

Jayaganden admitted that the recurrence rate of complex coronary angioplasty is about 5 to 10% higher than that of ordinary coronary heart disease treatment surgery. However, most patients achieve very satisfactory results after surgery, including alleviation of chest pain and dyspnea. Patients with unhealthy myocardium may also have a chance to improve their heart function and gradually return to a normal life track.

CABG still carries risk of recurrence

Some patients may be at risk for blockage again due to disease, such as severe hardening of cholesterol problems, kidney disease, etc. The probability of blockage is higher than that of others.

So can this group of patients choose CABG to reduce the risk of recurrence? There are indeed studies showing that CABG is more effective for this group of people, but there is still the possibility of re-obstruction many years later. In fact, a small group of patients still face the same problem even after multiple treatments, and this may be related to genes.

The patient himself should change himself as much as possible, including controlling blood sugar, cholesterol, blood pressure, lifestyle, controlling diet, exercising more, etc.

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