Revascularization

Revascularization

Revascularization

surgical procedure to help provide new or additional blood supply to an organ

Lesions w/ at LEAST 50% stenosis are…(2)

• Clinically significant

• Revascularization intervention needed

2 revasc interventions

• Coronary Artery Bypass Surgery (CABS)

• Precutneous Transluminal Coronary Angioplasty (PTCA)

3 aims of revasc

• Increase BF & O2 delivery to ischemic myocardium

• Decrease consequences of myocardial ischemia

• Decrease morbidity and mortality

3 characteristics of Myocardial Ischemia

• ST segment DEPRESSION

• Angina

• Threatening Arrhythmias

Unstable vs Stable ANGINA

Unstable = unpredictable (revasc more effective)

Stable = predictable (w/ exertion or PA)

Vessels used for CABS (4)

• Saphenous Vein

• Internal Mammary Artery (aka internal thoracic artrey)

• Gastroepiploic Artery

• Radial Artery

What is CABS

grafting a vessel to use in place of a coronary artery

Saphenous Vein pros & cons

PRO: Superficial and easy to remove

CON: Vein and will rupture over time

Average vein pressure

2-3 mmHg

Internal Mammary Artery pros & cons

PRO: Artery, most ideal

CON: Difficult to remove

Gastroepiploic Artery pros & cons

PRO: Artery

CON: Deep artery near major organs

Radial Artery pros & cons

PRO: Easy to remove

CON: Small

Patients at risk for CABS procedure (6)

• Old people

• Diabetics

• Women

• Obese clients

• EF <30%

• Emergency bypass surgery clients

What is PTCA

procedure to open blocked or stenosed coronary arteries

PTCA procedures (3)

• Balloon method

• Rotational Atherectomy/Rotoblater

• Directional Atherectomy (lasers)

Risks of PTCA (6)

• 30% clients develop restenosis in 6 months

• Infection

• Vessel Damage

• Embolism

• Angina

• Ruptured coronary artery

Candidacy factors for Revasc (5)

• Site of lesion (where)

• Stability of plaque (good or bad?)

• Symptoms

• Short & long term prognosis

• QOL

Candidates for CABS (2)

• Post-PTCA w/ restenosis (if PTCA doesnt work)

• Difficult vessel location

  • curve

  • distal location

Candidates for PTCA (3)

• Stable angina is unresponsive to meds

• Acute occlusion during MI

• PTCA patients must consent to emergency CABS

CABS hospital stay

2-5 days

PTCA hospital stay

1-2 days

CABS reduces _____ ___ _____ and __ , but carries a greater risk for _____

risk of death, MI, stroke

Why did incidence of revasc decrease btwn 2018-2020?

covid

For every _____ improvement in exercise capacity, mortality _____ by _____

1 MET (3.5 ml/kg/min), decreases, 8-17%

Should EXERCISE TESTING be performed after a successful CABS procedure

HELL NO

What is a more appropriate time for CABS patients to start exercise testing (4)

4 weeks post-CABS

• incisional pain resolved

• blood volumes normal

• muscle strength & endurance improved

When can exercise testing be performed on PTCA patients?

after 1-2 days

What adverse events have been reported during ex test post-PTCA? (2)

• acute thrombotic occlusion

• ischemia post-test

Strenuous short-term exercise _____ effect of ____

impairs, asprin

Cardiorespiratory exercise tests (2)

• Bruce protocol (young & fit)

• Naughton protocol (older)

Strength exercise tests (2)

• Peak force and torque

• 3-10 RM test

Flexibility exercise tests

• Sit-and-reach

• Goni

CABS patient resistance training guidelines for 1st 4 weeks (5)

• ROM w/ no weight

• Increase 1-2lbs after easily performing 12-15 reps

• 30-45 sec rest

• No tight grip

• No valsalva

CABS patients resistance training plan order

WEEK:

0-4: ROM

4-6: Early Phase

6-8: Mid Phase

8+: Late Phase

PTCA patients resistance training plan order

WEEK:

0-4: Early Phase

4-6: Mid Phase

6-8: Late Phase

8+:

Early Phase Rehab muscles worked

• Legs

• Small UB muscles

• NO LARGE UB MUSCLES

examples: seated leg ext, leg curl, calf raise, db curl, tricep pushdown

Mid Phase Rehab muscles worked

• Adding shoulders and back

• NO CHEST

examples: seated row, shoulder press, lat db raise

db bent over row, tricep kickback

Late Phase Rehab muscles worked

• Add chest

examples: lat pulldown, db bench press, db fly, front raise

CABS special considerations (3)

• Incisional discomfort

• Soreness

• Hesitant to do ROM/stretching

PTCA special considerations (2)

• groin soreness @ insertion site

• restriction of movements

General consideration

Patients will be on extremes of mental state (depressed or too confident)