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Heart catheter: stent treatment for CHD

Coronary heart disease leads to a narrowing of the coronary arteries.  However, surgery (a bypass) is not always necessary. Often, a so-called "stent" – a vascular support – can be applied, which reestablishes blood flow into coronary artery again.

Herzkranzgefäße: Blutversorgung des Herzens Blood is supplied to the muscle tissue of the heart (the myocardium) by the coronary arteries. In general, a person has three coronary arteries: the right coronary artery (RCA), which primarily supplies the rear wall portions and the right ventricle, the left coronary artery (LCA), which arises usually from a so-called main stem and then enters into the left anterior descending  (LAD) and divides the side wall artery (ramus circumflex; RCX). Extending from these branches are major sub- branches that supply the heart muscle itself. The major branches lie in the fatty tissue near the outer layers of the heart (epicardium), therefore, these vessels are also called epicardial vessels.
 
The major diagonal branches extend off the LAD, marginal branches stem from the RCX and the RCA divides mostly at the so-called "crux of the heart" (crux cordis) into the posterior interventricular artery (RIVP) and the ramus posterolateral dexter artery(RPLD). This information can be found in diagnoses and medical reports for the localization of interventions (angioplasty, stent implantation), and also for the suturing of bypasses. Blood supply regulation is not the same in all people. There are patients with a uniform blood supply and others for whom the blood flow is fed predominantly from the left or right coronary artery.
Coronary vessels (Photo: Medtronik)  
Blood is supplied to the muscle tissue of the heart (the myocardium) by the coronary arteries. In general, a person has three coronary arteries: the right coronary artery (RCA), which primarily supplies the rear wall portions and the right ventricle, the left coronary artery (LCA), which arises usually from a so-called main stem and then enters into the left anterior descending  (LAD) and divides the side wall artery (ramus circumflex; RCX). Extending from these branches are major sub- branches that supply the heart muscle itself. The major branches lie in the fatty tissue near the outer layers of the heart (epicardium), therefore, these vessels are also called epicardial vessels.The major diagonal branches extend off the LAD, marginal branches stem from the RCX and the RCA divides mostly at the so-called "crux of the heart" (crux cordis) into the posterior interventricular artery (RIVP) and the ramus posterolateral dexter artery(RPLD). This information can be found in diagnoses and medical reports for the localization of interventions (angioplasty, stent implantation), and also for the suturing of bypasses. 
Blood supply regulation is not the same in all people. There are patients with a uniform blood supply and others for whom the blood flow is fed predominantly from the left or right coronary artery.
If a circulatory disorder is detected during a stress test (stress echocardiography, cardiovascular MRI), it may become necessary to eliminate the constriction (stenosis) that is causing it. The first step is usually is to "expand" the vessel with a balloon. In this procedure, an angioplasty, narrowed tissue is pushed outwards in order to create more space for blood flow. In the past, this was the preferred method, but today we know that the bottlenecks can quickly re-form, damage such as a rupture (dissection) on the vascular inner surface (endothelium) can also occur.
Therefore, today, stents capable of keeping the vessel open for the long-term and can also cover minor cracks in the inner surface of the vascular wall are implanted almost always in the same session. The technical process is very similar to the balloon dilatation and stent implantation.

KHK: PTCA (Ballon-Dilatation) eines Kranzgefäßes

PTCA (balloon expansion) of a coronary vessel
(Photo: Medtronic)

Stent Implantation

Stent implantation (Photo: Medtronic)

In a stent implantation, a very fine wire is inserted into the coronary artery through the cardiac catheter. A balloon system on which the stent is mounted is conducted through the wire to the point of the constriction. The wire serves as a rail. An X-ray then displays the exact position of the stent in the coronary artery. By applying pressure the balloon expands in the stenosis. In doing so, the stent is then pressed into the tissue which is then expanded out from the vessel interior. After the procedure, the wire and balloon are removed, the stent remains. Blood is now able flow freely through the vessel again. Modern imaging technology and recent developments in material properties make it possible that, in many cases, where once a bypass surgery was inevitable, the stent treatment is sufficient.
As with each procedure, the stent treatment also has its limits. Not every constriction can or should be provided with a stent. In particular, data has demonstrated that if no constriction of the blood flow (ischemia) exists, stent treatment for coronary heart disease offers no benefit when compared to drug therapy. Therefore, in treatment centers adhering to current guidelines, a comprehensive and accurate diagnosis is performed. Naturally this does not apply to acute emergency situations. In an acute vascular occlusion (myocardial infarction), there is always a circulatory disorder that leads to characteristic changes in ECG and echocardiography test results changes and lead to detectable vascular wall motion abnormalities.

 

The stent keeps the coronary vessel safely open. In order for it to remain that way, a special medication treatment is required. After a stent procedure a dual-therapy involving aspirin + platelet inhibitors (usually clopidogrel) is administered, either for a period of 4 weeks for a non-coated stent or a 12 month treatment for a drug eluting stent. Following this treatment, a single therapy with aspirin is usually sufficient. These drugs are designed to prevent the formation of blood clots in the new structure. The stent is eventually completely covered by the body's own cells (endothelium), so after this process is completed, blood clots are not to be expected there. In some cases, a re-narrowing (restenosis) may occur in the region of the stent or the stent exit. This can be an expression of an accelerated vascular disease, on the other hand, a reaction to the stent procedure. A re-narrowing can also be treated with a renewed balloon expansion or a stent-in-stent procedure. Promising developments include new balloons which are also coated with medication.

Stent in the coronary artery ( Photo: Medtronic)

There are certain factors which allow for predicting the risk of re-narrowing (restenosis). In such cases, a so-called drug- coated stent should - if possible - be used. After the procedure, the substances deposited on the stent can later inhibit a proliferation of narrowing within the vessel. This safeguards the long-term success after the procedure. Combined with optimal medication and other precautionary measures, stent implantation can lead to positive, long-term results. Regular check-ups (e.g. stress echocardiography) can help detect early restenosis before a heart attack occurs.
The cardiac catheter examination by an experienced internist is the best way to assess which stent type is ideal for a patient’s particular condition. The coated stent is not always the best alternative. More recent systems (e.g. absorbable stents) have respective advantages and disadvantages that must be taken specifically into account. In every case, an accurate diagnosis before and after the surgery by the cardiologist and general practitioner are important to the long-term outcome.

Invasive cardiology at the Isar Heart Center

  • Coronary Heart Disease (CHD)
  • Heart Attack
  • Stent Therapy
  • Congestive Heart Failure
  • Bare-Metal Stents
  • Heart Failure Therapy (ASD, VSD, PFO)
  • Coated Stents
  • Myocardial Blood Flow
  • Self-resolution Stents
  • Hybrid laboratory
  • Intravascular Ultrasound (IVUS)
  • Heart Catheter System
  • Diagnosis and Treatment of Renal Diseases
  • Myocarditis
  • Modern Imaging (Fusion Imaging)
  • Pericardial disease

 

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