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The heart has 3 layers of tissue:

  • Pericardium – The thin outer layer that protects the heart
  • Myocardium – a thick muscular middle layer that contracts and pumps out blood
  • Endocardium – a thin inner lining

Inside the heart, there are four chambers- the upper two are right and left atria and lower two are right and left ventricles. The atria receive the blood that comes to the heart and the ventricles pump blood out from the heart. The right and left side of the heart is separated by a septum.

The heart also has 4 valves which allow unidirectional flow of blood every time the heart beats.

  • the tricuspid valve is between the right atrium and right ventricle.
  • The pulmonary valve is between the right ventricle and the pulmonary artery.
  • The mitral valve is between the left atrium and left ventricle.
  • The aortic valve is between the left ventricle and the aorta.

The electrical system of heart:

The pumping action of the heart is controlled by the heart’s electric system. As an electrical impulse moves through the heart muscles, the various chamber of heart coordinate and pump out blood.

An electrical stimulus is generated by the sinus node (also called the natural pacemaker) which is located in the right atria of the heart. This stimulus activates the atrial muscles. The electrical stimulus then travels down through the conduction pathways and causes the heart’s ventricles to contract and pump out blood. The atria contract first, just a few milliseconds before the ventricles. This allows the blood from the atria to enter into the ventricles which is pumped out later.


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Mitral stenosis is the narrowing of the valve present between the left chambers of the heart (mitral valves), thereby blocking the blood flow. This condition usually develops several years after a person had a rheumatic fever. Mitral stenosis is treated with balloon valvotomy, when the medications do not reduce the symptoms. If left untreated, mitral stenosis can result in various heart complications.

Mitral valvotomy (or valvuloplasty), also known as percutaneous balloon dilation, is a minimally invasive procedure that involves widening a mitral valve using a balloon catheter, a thin, flexible tube with a balloon at the tip. This procedure improves the overall function of the heart.

What are the risks of mitral valvuloplasty?

The risks associated with percutaneous balloon dilation include:

  • Blood clot formation or tears in the heart
  • Backward flow of the blood (mitral valve regurgitation) due to damaged valve
  • Restenosis of the mitral valve

What happens before the procedure?

Your doctor will explain the procedure in detail and provide you the opportunity to ask any questions; do not hesitate to ask any questions related to the procedure.

Your healthcare team will give you certain instructions to prepare for the procedure:

  • You will be asked not to eat or drink anything after midnight, on the previous night of the procedure; you can drink water up to 4 hours of the procedure.
  • A blood test may be done to evaluate the time required for the blood to clot; other blood tests may also be performed.
  • You may be asked to stop taking certain medicines that may involve with the blood clotting process.

Notify your doctor if you:

  • Had an allergic reaction to any contrast dye, iodine or seafood.
  • Are sensitive to any medications, tape, latex, or anaesthetic agents.
  • Have a pacemaker.
  • Have any body piercings on the abdomen or chest.
  • All the medications you are taking, including over-the-counter drugs, herbal supplements, blood thinners, etc.
  • Have heart valve disease, as antibiotic drugs may be given before this procedure.
  • Have a history of bleeding disorders
  • Are or may be pregnant

Before the procedure, the area near the catheter insertion site (the groin area) may be shaved. Your physician may order other preparations for the procedure based on your medical condition.

How is mitral valvuloplasty performed?

On the day of the procedure, you should remove your jewellery and other objects that may interfere with the procedure. You will be asked to change into a hospital gown and empty your bladder before the procedure.

An intravenous (IV) line will be attached to your arm or hand to inject medications and administer IV fluids, if needed. You may receive a sedative to help you relax.

The following are the steps generally involved in a balloon valvuloplasty:

  • A local anaesthetic is injected at the insertion site.
  • Once the anaesthesia sets in, a sheath or an introducer (a plastic tube) will be inserted into the blood vessel.
  • A valvuloplasty catheter is inserted through the sheath into the blood vessel. The catheter is advanced through the aorta into the heart valve. The catheter may be guided by a fluoroscopy (a special x-ray).
  • Once the catheter reaches the precise location, a contrast dye is injected into the valve to get a clear image of the area.
  • The balloon is then inflated and deflated several times.
  • The catheter is then removed.
  • The catheter insertion site is closed using a sterile bandage.

What happens after the procedure?

After the procedure, you will be moved to the recovery room. You should remain flat on bed for several hours after the procedure. Your vital signs, and circulation and sensation in the affected arm or leg, the insertion site will be monitored regularly.

Medicines may be given for pain or discomfort near the insertion site. You will be asked to drink water and other fluids to eliminate the contrast dye from your body. You can return to your regular diet after the procedure.

Mostly, you may have to spend the might in the hospital, based on your medical condition and recovery.

Your healthcare team will give you instructions to be followed after leaving the hospital:

  • Keep a check on the insertion site for unusual pain, bleeding, swelling, or discoloration.
  • Keep the insertion site clean and dry.
  • Do not participate in any strenuous activities. Your doctor will inform you when you can resume normal activities and return to work.

Call your doctor immediately if you have any of the following:

  • Fever or chills
  • Severe pain, swelling, redness, bleeding or other leakage from the insertion site
  • Numbness, coolness or tingling sensations in the affected extremity
  • Pain or pressure in the chest, nausea or vomiting, sweating, or dizziness
  • Reduced urination
  • Swelling of the abdomen or extremities
  • Over 3 pounds weight gained in a day

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Cardiac disease is the common cause of death throughout the world. Among these, 85% of death are due to heart attack and stroke.

A heart attack occurs when the cholesterol plaque accumulates in the walls of the coronary arteries (blood vessels that deliver blood to the heart). People with the possible symptoms of a heart attack can confirm the diagnosis by coronary angiography. Coronary angiography is a procedure that combines contrast dye and X-rays to identify the blockages in the coronary arteries.

When is coronary angiography done?

Coronary angiography is an important part of clinical evaluation in patients who have:

  • Persistent angina despite full medications
  • Ischemic heart disease
  • Cardiomyopathy
  • An abnormal heart stress test
  • Unexplained congestive heart failure
  • Acute myocardial infarction
  • Large ventricular septal defects, which may increase the risk of heart failure

It is also used as a pre-operative procedure in individuals with scheduled heart surgery, who have a high risk of coronary artery disease.

Risks of coronary angiography:

The following are the possible complications associated with coronary angiography:

  • Bleeding at the site of incision
  • Blood clots
  • Infection
  • Irregular heart rhythms
  • Kidney damage
  • Risk of stroke

What happens before the procedure?

Coronary angiography is usually performed on an emergency basis. If the procedure is scheduled in advance, then the person may need to follow these instructions:

  • Inform about all the past and present medical conditions.
  • Tell about the current medications.
  • Notify the doctor regarding any allergies.
  • Eight hours before the surgery avoid eating or drinking anything.

How is Coronary Angiography performed?

Before initiating the procedure, a sedative is given through the IV line to calm the person. Local anaesthesia is administered either on the arm or groin region.

Once the anaesthesia sets in, an incision is made to insert the catheter into the artery. By using the X-rays, the catheter is guided to reach the coronary artery. Once the catheter reaches the artery, a contrast dye is injected to highlight the blockage. This blockage is observed on the X-ray monitor.

What to expect after the procedure?

Once the catheter is removed, the incision will be closed with a manual clamp. For the first few hours, you will be in a recovery room, where your vitals are checked. You need to lie straight for a few hours to avoid bleeding from the incision site.

Before discharge, the doctor may give you the following instructions:

  • Consume plenty of fluids to flush out the contrast dye from the body.
  • Take the prescribed medications.
  • Do not lift heavy weights for a few days
  • Avoid strenuous activities for a couple of days.
  • Have a healthy and well-balanced diet.
  • Maintain healthy body weight.

When to seek medical attention?

Visit the doctor immediately on noticing any of the following symptoms:

  • Bleeding
  • Infection at the site of catheter insertion
  • Pain, discomfort, and inflammation at the incision site
  • Change in the colour or temperature at the operated area (arm or leg)
  • Weakness or dizziness
  • Chest pain
  • Shortness of breath

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Carotid artery disease is a condition that arises when the fat deposits accumulate and block the blood vessels that deliver blood to the brain. People with carotid artery disease are at higher risk of developing stroke. So, to determine the risk and prevent the associated complications, a procedure known as cerebral angiography is recommended.

Cerebral angiography is a diagnostic procedure that uses X-rays to evaluate the blockage or any brain abnormalities in the carotid arteries (blood vessels in the brain and neck).

When is cerebral angiography recommended?

Cerebral angiography is recommended if the doctor suspects any of the following abnormalities within the brain:

  • An aneurysm
  • A dilated blood vessel in the brain
  • Brain tumour
  • Brain clot
  • Stroke

It is also used to evaluate arteries in the head and neck before undergoing any surgery; to provide additional information regarding any abnormalities that are not visible on other imaging tests, and as a minimally invasive procedure to treat vessel abnormalities.

In some cases, it is done to determine the underlying cause of the following symptoms:

  • Severe headache
  • Memory loss
  • Dizziness
  • Blurred vision
  • Loss of balance or coordination
  • Weakness or numbness

Before the procedure:

Specific instructions are given before undergoing the procedure. These instructions may include:.

  • Any allergies
  • The use of current medicines, vitamins, and mineral supplement
  • The current medical conditions
  • Any food or dietary restrictions before the procedure.

What happens in the procedure?

Before initiating the procedure, the patient’s head is stabilized by using a strap, tape, or sandbags. Based on the age of the person, either local or general anaesthesia, is administered. Once the anaesthesia sets, the doctor will sterilize the groin region and make an incision. Under the guidance of X-rays, the catheter is passed into an artery in the neck.

Once the catheter is placed in the correct position, the contrast dye is injected to highlight the blockage. After the X-rays are done, the catheter is removed, and the incision is closed.

What to expect after the procedure?

Once the procedure is done, the vitals are monitored in a recovery room. The person would be instructed to keep the leg straight if the catheter is administered through the groin region. Pain and inflammation at the site of incision are common, which can be relieved by applying ice packs and taking the prescribed medicines.

What considerations should be taken after the test?

Cerebral angiography is a diagnostic procedure, so there are not much considerations. However, following the below-given tips may ease the discomfort associated with the test:

  • Have a healthy and well-balanced diet.
  • Do not lift heavyweight for a few days or as suggested by the doctor.
  • Perform normal activities 8 to 12 hours after the procedure.

Talk to the doctor:

Call the doctor immediately on noticing any of the following symptoms:

  • Chest pain
  • Dizziness
  • Infection at the catheter site
  • Shortness of breath
  • Skin rash
  • Slurred speech
  • Vision problems
  • Numbness in the face, arms, or leg muscles

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Hemodialysis is a preferred treatment option for patients with chronic kidney disease. In this t procedure, the blood is filtered outside the body by a dialyzer or “artificial kidney”. For hemodialysis, a vascular access is created to insert the needles that connect the dialyzer, thereby allowing the blood to move out and return to the body at a high rate. An arteriovenous fistula is the preferred vascular access for hemodialysis.

An arteriovenous (AV) fistula is created by connecting an artery to a vein, usually in the wrist or upper arm. But sometimes, the fistula can become infected, blocked or narrowed. The blocked fistula can be treated by a balloon fistuloplasty.

What is balloon fistuloplasty?

Balloon fistuloplasty is a procedure in which any blockage or narrowing in the fistula is located by using a dye, and the blockage is relieved by stretching the blood vessels with a special balloon.

In this procedure, a small balloon is inflated for several times at the narrowed regions of a fistula; if required a stent may also be placed. This technique widens the lumen and facilitates the process of dialysis.

Why perform fistuloplasty?

A fistula can age and cause problems like clotting and scarring, thereby decreasing its function and effectiveness of dialysis. Clots can decrease the rate of blood flow or block the fistula completely. If these problems are left untreated, it may lead to the failure of fistula.

Thus, it is important to treat the narrowing or blockage at an early stage, so that the fistula works well, and dialysis occurs without any complications.

What are the risks of dialysis fistuloplasty?

Fistuloplasty is usually a safe procedure, but some complications may occur rarely. The common risks and complications associated with fistuloplasty include:

  • Bruising around the site of insertion of the needle, which may become large and uncomfortable (rarely).
  • Infection of large bruises, which may need antibiotic treatment or surgical intervention.
  • Allergic reaction to the dye, which may present as a skin rash
  • Circulatory problems due to the damage to the artery or fistula caused by catheter or balloon
  • Treatment failure, which will require surgical intervention

How to prepare for the procedure?

Your healthcare provider will give you instructions to prepare for the procedure, which may include:

  • You may be asked not to eat or drink anything for six hours before the procedure; you can drink water up to two hours before.
  • Some blood tests may be performed before the procedure to evaluate the risk of bleeding.
  • If you are diabetic, ask your doctor to alter the treatment regimen.
  • Ask your doctor which medicines you can continue to take, and which ones you should stop.
  • If you are taking any antiplatelets or anticoagulants, you may have to stop taking these medicines a few days before.
  • Ensure that you have an adult to drive you home and accompany you overnight.

Inform your healthcare provider if you:

  • Are allergic to iodine, or have any other allergies
  • Have a history of reaction to the dye used for CT scan or X-rays
  • May be or are pregnant
  • Are a diabetic

What happens during the procedure?

The following are the steps usually performed in a fistuloplasty:

  • You will be asked to lie on your back on an x-ray table. Some monitoring equipment will be attached to measure your heart rate and blood pressure.
  • The interventional radiologist will observe the fistula by using an ultrasound, which provides a clear picture of the fistula.
  • A small needle is inserted in the fistula, and a contrast dye is injected. This provides an image of the blood vessels, which helps to locate the narrowing or blockage.
  • A catheter (a small, flexible tube) with a balloon at the tip is then inserted in the blood vessel to reach the precise location.
  • Once the catheter reaches the site of the blockage or narrowing, the balloon is inflated and deflated several times from outside the body.
  • Sometimes, if the balloon does not improve the fistula, a permanent stent may be used to widen the narrowing.
  • Then the catheter is removed from the blood vessel, and the puncture site is stitched to prevent bleeding.

Usually, fistuloplasty takes about one hour, but the duration may vary in different patients.

What happens after the procedure?

You will have to stay in the hospital after the procedure for three to four hours for observation. Your pulse, blood pressure and oxygen levels in the body will be monitored regularly. You may return to your normal diet. The fistula is ready to use immediately after the procedure.

Your nurse will tell you when you can go home. You will need a friend or a family member to drive you home; using public transport is not recommended.

Your fistula should be ready for use immediately after the procedure.

What measures do I take after going home?

The following measures will help you recover better after a fistuloplasty:

  • Rest well on the day of the procedure and the next day. Then, you can return to your normal activities.
  • You can follow your normal diet.
  • Take the pain killers as prescribed r instructed.
  • Continue to take you regular medicines, as prescribed.
  • Do not take metformin until two days after the procedure.
  • You can have a bath or shower the next day.

Call your doctor immediately

if you have any of the following symptoms:

  • A lot of swelling and bruising
  • Severe pain at the puncture site that does not get better with painkillers
  • Bleeding at the puncture site
  • Change in the colour of your arm
  • Fever or chills
  • A lump, pus or discharge at the puncture site
  • Difficulty breathing or chest pain

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Cardiac catheterization is one of the most extensively performed cardiac procedures. If you have chest pain or irregular heartbeat, your doctor may recommend cardiac catheterization.

Cardiac catheterization is a minimally invasive procedure used to detect and treat cardiovascular diseases. This procedure involves the insertion of a catheter (a thin hollow tube) into the large arteries or veins present in the neck, arm or groin, which is then guided to the heart using a special X-ray. Once the catheter reaches the location, diagnostic tests or treatment procedures are carried out.

Why perform Cardiac Catheterization?

Cardiac catheterization is done to find the cause of the signs and symptoms of a heart problem or to treat or repair the heart damage.

This procedure is performed to:

  • Determine the pressure levels in the chambers of the heart.
  • Determine the heart function after a cardiac intervention.
  • Detect blockages in the coronary arteries (coronary angiography) or valve dysfunction.
  • Perform procedures such as angioplasty, ablation therapy or valve repair.
  • Obtain a small piece of heart tissue to examine under a microscope for detecting conditions affecting the heart muscle (cardiac biopsy).

What is the difference between Cardiac Catheterization and Coronary Angiography?

Catheterization is a procedure used to diagnose and treat various conditions. It involves the insertion of a catheter into the arteries and veins to reach the heart and to measure how much blood the heart pumps out, the pressure in each heart chamber, and to detect any defects in the heart. Also, various small instruments can be inserted into the catheter to view the interior of the blood vessels, to remove a tissue sample from the heart for further examination, etc.

Coronary angiography is a type of catheterization procedure, which involves analysing the arteries that supply the heart with oxygen-rich blood. This procedure involves the insertion of a catheter in the arm or the groin, which is threaded to reach the coronary arteries. During insertion, fluoroscopy (a continuous x-ray procedure) is used to guide the catheter to reach the precise position. After the catheter tip is at the right location, a contrast dye is injected into the coronary arteries. This dye can be seen on x-rays, and the outline of the arteries is viewed on a video screen.

How do I prepare for the procedure?

Inform your doctor about:

  • The medications that you are taking, especially blood-thinners or anti-inflammatory medications
  • Any medical conditions that you have
  • Allergies to any dyes or specific medications

Before the procedure:

  • Fast for at least 6 hours, as food and liquid increase the possibility of complications with general anaesthesia.
  • Empty your bladder before heading to the procedure.
  • Remove dentures and jewellery, as they may interfere with the imaging procedures.
  • Your general health status and vital signs will be monitored.

What happens during the procedure?

During cardiac catheterization, an IV cannula is inserted in your arm to administer medications. You will be given a mild sedative to help you relax during the procedure.

The general procedure of cardiac catheterization is given below:

  • The site of catheter insertion (usually the groin) is cleaned and shaved.
  • Usually, local anaesthesia is administered. General anaesthesia may be given before surgical procedures such as valve repair or ablation.
  • When the site of catheter insertion becomes numb, an incision is made, and the catheter is inserted using a catheter sheath.
  • Once the catheter reaches the heart, a dye is administered which outlines the vessels, valves and chambers of the heart.
  • The diagnostic tests or surgical procedures will then be performed for treating the condition.

Vital signs and electrocardiogram will be continuously monitored during the procedure.

Cardiac catheterization usually lasts for about 30 minutes. It may be longer if you are undergoing any other test or intervention using this procedure.

After the procedure is done, the catheter will be removed, and the incision will be closed by stitches. A sterile dressing will be used to prevent infection in the incision site.

What happens after the procedure?

Once the procedure is done, you will be asked to lie flat on the bed for 2-6 hours after the procedure. Your heart rate and blood pressure will be continuously monitored.

Once the anaesthesia wears off, you will be given pain medications. You will be asked to drink plenty of water to eliminate the dye that was administered. Usually, you will be asked to stay in the hospital for a few hours or a day.

After leaving the hospital, follow all the post-procedural instructions given by your doctor. You may resume your normal activities in a day’s time. Some soreness at the incision site is normal; it may reduce within a week.

What are the risks of Cardiac Catheterization?

Cardiac catheterization is a relatively safe procedure. However, like any other invasive procedure, some uncommon risks of this procedure are:

  • Infection
  • Blood clotting
  • Bruising at the incision site
  • Allergic reaction to dye
  • Arrhythmia
  • Air embolism
  • Stroke

Call your doctor if you experience:

  • Severe pain at the incision site
  • Signs of infection: redness, warmth, pus oozing or excessive swelling around the incision site
  • Numbness or tingling sensation in your limbs

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Peripheral arteries are the blood vessels that deliver blood to the lower limbs. When the cholesterol accumulates in these blood vessels, the blood flow to the lower limbs gets blocked. Peripheral angioplasty is a minimally invasive procedure. It is done to restore the blood flow by opening the blocked peripheral arteries.

When is peripheral angioplasty performed?

  • Peripheral angioplasty is mostly indicated in the treatment of Peripheral Vascular Disease (the circulatory disorder caused by the blocked or narrowed blood vessels outside the heart).
  • Peripheral artery disease is the common condition, in which peripheral angioplasty is recommended.

Are there any risks with peripheral angioplasty?

Peripheral angioplasty is associated with the following risks:

  • Breathing problems
  • Bleeding
  • Blood clots
  • Infection
  • Kidney damage
  • Damage to the blood vessel

How to prepare for the procedure?

Before initiating the procedure, a physical examination and imaging tests are done to determine the overall health condition. Additionally, the following steps would help in a successful procedure and quicker recovery:

  • Inform the use of current medications, vitamin or mineral supplements.
  • Tell the doctor about any underlying disease condition.
  • Take the prescribed medicines.
  • Notify the doctor if you have any allergies.
  • Six to eight hours before the surgery do not eat or drink anything.

What happens during the procedure?

Local anaesthesia is administered in the upper thigh region. Once the anaesthesia sets, an incision is made on the upper thigh to insert the catheter. By using a high-resolution fluoroscopic, the catheter is guided to the blocked artery. When the catheter reaches the obstructed artery, the balloon is inflated to widen the blood vessel. Once the blood flow is restored, a stent is placed to prevent the risk of further blockage. Finally, the incision is closed and covered with a sterilized bandage.

What to expect after the procedure?

You will be placed in a recovery room and the vital parameters would be checked. For at least 3-6 hours, you need to remain still, to prevent bleeding from the incision site. Depending on the patient’s condition, the doctor will decide whether the person requires a hospital stay or not.
Before discharge, you will receive the following instructions:

  • Keep the wound clean and dry.
  • Do not lift heavyweights.
  • Avoid strenuous exercises for at least 24 hours after the procedure.
  • Drink plenty of fluids to help flush out the contrast dye from the body.

Care after peripheral angioplasty:

Although peripheral angioplasty clears the blockage, it does not treat the underlying cause of the blockage. So, to prevent the further risk of blockage, the following steps should be taken:

  • Maintain a healthy body weight.
  • Quit smoking.
  • Exercise regularly.
  • Take the prescribed medicines to prevent re-narrowing of the blood vessels.
  • Manage stress.
  • Avoid fatty-foods.
  • Have a low-salt and low-fat diet to prevent the risk of fluid retention.

Seek medical attention:

The following symptoms are the warning signs that require immediate medical attention:

  • Swelling in limbs
  • Chest pain
  • Shortness of breath
  • Fever associated with chills (over 101oF)
  • Weakness
  • Dizziness

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Critical limb ischemia (CLI) refers to severe compromise of blood flow to alimb (hands or legs) which causes severe limb pain at rest or even loss of limb. It is the most advanced form of peripheral artery disease.

CLI numbers:

  • Prevalent in 2% patient over 70 years of age.
  • Within 1 year of diagnosis, 40-50% patientshave an amputation and 25% die.

How CLI leads to amputation?

Amputation occurs when there is marked ischemia of the limb owing to reduction of blood flow and increase demand in the limb.

Factors that reduce blood supply:

  • Diabetes mellitus
  • Severe Renal or Heart failure
  • Vasospastic diseases
  • Smoking

Factors that increase demand for blood flow:

  • Infection (cellulitis)
  • Skin breakdown
  • Trauma
  • Osteomyelitis

 Diagnosis of CLI:

Characteristic Duplex Ultrasound Digital – Subtraction Angiography Magnetic Resonance Angiography (MRA) Computed Tomographic Angiography (CTA)
Advantages
  • Noninvasive
  • Can Visualize & Quantitate severity
  • Gold Standard
  • High Resolution
  • Can guide intervention
  • Noninvasive
  • No radiation
  • No contrast
  • 3 D
  • Noninvasive
  • Higher Resolution than MRA
  • 3 D
Disadvantages
  • Operator dependent
  • Limited by
    dense calcification
  • Invasive
  • Radiation
  • Contrast
  • 2Dimensional
  • Lower Resolution than CTA
  • Claustrophobia
  • Contrast Image artifact if stent present
  • Radiation (25% of dose with DSA)
  • Contrast
  • Limited by calcification

Management plan for critical limb ischemia:

Critical Limb Ischemia Non-Healing Ulcer Rest Pain

MRA, CTA or invasive argiography shows lesion treatable by endovascular approach

  • Endovascular revascularization ->Wound care and atherosclerosis risk factor modification
  • Lesion treatable by open sugery at acceptable operative risk
    • Surgical revascularization ->Wound care and atherosclerosis risk factor modification
    • Consider primary amputation ->Wound care and atherosclerosis risk factor modification


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Carotid arteries are the major blood vessels on each side of the neck that supply blood to the brain, face and neck. These arteries extend from the aorta in the chest to the base of the skull.

Over time, the arteries can harden and cause a build-up of plaque (calcium, cholesterol, and fibrous tissue deposits) on the walls of the arteries. This plaque build-up can narrow and stiffen the arteries. The progressive plaque build-up can reduce the blood flow through the arteries or cause the formation of blood clots. Such narrowed carotid arteries can be treated by using stents.

Carotid artery stenting (CAS) involves the insertion of a metal-mesh tube, called a stent, at the site of clogged arteries, to expand the lumen of the arteries and increase the blood flow to the brain.

What are the indications and contraindications for CAS?

The indications for CAS include:

  • High risk of stroke
  • Carotid artery blockage of 70 percent or more
  • Intolerance to general anaesthesia for carotid endarterectomy (an open surgery to remove the plaques in carotid arteries and to reduce the risk of stroke)
  • Damage to the contralateral vocal cord caused by previous carotid endarterectomy or neck surgery
  • Narrowing of carotid artery after previous CEA
  • Neck irradiation

The contraindications for CAS are:

  • Allergic reaction to intravenous (IV) contrast dye in the past
  • Unstable carotid or aortic arch plaque
  • A recent stroke in less than 14 days
  • Total thrombotic occlusion of carotid artery

What are the complications of CAS?

Here are some complications that may occur during or after CAS:

  • An embolism, blockage due to a clot or debris in an artery in the brain, a serious complication which can cause a stroke.
  • Formation of a blood clot along the stent or a tear in the artery wall (dissection).
  • Restenosis, the blockage of the carotid artery after the procedure.
  • Kidney damage, particularly in individuals with kidney problems, caused by the dye used for angiogram.
  • Bleeding from the incision site in the arm or groin artery, known as false aneurysm or hematoma (an unusual complication).
  • Mild tenderness and bruising at the puncture site, which usually resolves over time.

The factors that increase the chance of complications during CAS include:

  • Age > 80 years
  • High blood pressure
  • Allergy to contrast material
  • Sharp bends or other structural abnormalities in the carotid arteries
  • Significant atherosclerosis or plaque build-up in or near the carotid artery
  • Widespread blockages in the arteries in the legs and arms
  • Poor kidney function

How to prepare for CAS?

When planning for the procedure, inform your doctor about:

  • All the medicines that you take, including over-the-counter medicines, blood thinners, herbs, supplements, etc.
  • Habits like smoking; your doctor may help you quit smoking
  • Any changes in your health, like a fever
  • Are or may be pregnant
  • Allergies to medicines such as iodine, anaesthesia, or contrast dyes
  • Any pacemakers that you have
  • Any other medical condition that you have

Some tests may be performed before the procedure, including:

  • Blood tests, to check for infection and anaemia
  • A chest X-ray, to view the heart and lungs
  • An electrocardiogram (ECG), to assess the heart rhythm
  • Ultrasound of the neck, to assess the carotid artery
  • Computed Tomography (CT) angiogram of the blood vessels in the neck and head

Your healthcare team may give you some instructions to prepare for the procedure, which may include:

  • You may be asked to stop some medicines, such as blood thinners, a few days before the procedure
  • Ask your doctor which medicines you can take on the day of the procedure, and which medicines you should stop taking.
  • Do not eat or drink after midnight, the night before CAS.
  • Make sure you have an adult to drive you home on the day of the procedure

What happens during CAS?

Although the exact steps of the procedure may vary, a typical CAS may go like this:

  • An intravenous (IV) line will be put in the arm before the procedure. Sedation will be given through this IV line to help you relax and sleep.
  • Local anaesthesia is injected near the groin region.
  • A small incision is made in the blood vessel in the groin region.
  • A thin, flexible tube called catheter, with a balloon at its tip is inserted into this incision.
  • The catheter is threaded through the blood vessel into the carotid artery.
  • X-ray images may be used to guide the catheter to reach the blocked region in the carotid artery.
  • The balloon is inflated and deflated several times inside the narrow part of the carotid artery.
  • A compressed stent is then inserted using the catheter to reach the affected area.
  • Once the stent is at the precise location, it is released. The stent expands to fit the artery.
  • The balloon catheter may be used to expand the stent further.
  • The balloon is deflated, and the catheter is removed.

What happens after the procedure?

After the procedure, you will be moved to the recovery room. Your vitals, like your breathing and heart rate, will be monitored. Pain medicines will be given if needed. You may have to lie down, without bending your legs for few hours to prevent bleeding from the incision site.

You can go home on the same day of the procedure, but some patients may have to stay in the hospital for the night. You should ask a family member or a friend to drive you home.

After leaving the hospital, you may have some pain or a bruise near the incision site. You may be given certain over-the-counter pain medicines, drugs to prevent blood clot formation or spasm of the blood vessels; your healthcare provider will instruct you the dose and when you should take these medicines. Rest well and avoid strenuous exercise for the next 24 hours at least.

Call your doctor immediately if you have:

  • Severe pain or swelling at the incision site that is progressing
  • Blood or fluid leakages from the incision site
  • Fever
  • Redness or warmth at the incision site
  • Chest pain

What measures do I take to stay healthy after CAS?

CAS opens the artery and ensures good blood supply to the brain. But this procedure does not stop building-up of plaque in the arteries. Therefore, to preventing hardening of the arteries, plaque formation and clogging of the arteries, take the following measures:

  • Eat foods containing low calories, cholesterol, and saturated fat.
  • Exercise regularly, particularly aerobic exercises like walking.
  • Maintain an ideal body weight.
  • Quit smoking.

cci-radiofrequency_ablation.jpg

Varicose vein is one of the most common venous disease in the legs, affecting 1 out of every 5 adults.

Varicose veins are twisted, swollen veins, which usually appear in the lower legs, but can affect any part of the body. This condition occurs when the valves that direct the blood flow in the veins are weak or damaged, resulting in the decreased blood flow to the heart, and subsequent backing up of blood within the veins, leading to the enlargement of the veins.

How are varicose veins presented in patients?

Varicose veins may be painful for some individuals; they are usually presented as:

  • Dark purple or blue coloured veins
  • Twisted, bulged, cord-like veins
  • Heaviness or aching in the legs
  • Muscle cramping, burning, swelling or throbbing in the legs
  • Pain gets worse after sitting or standing for a long time
  • Itchiness around the veins
  • Discoloration of the skin around the veins

How to diagnose Varicose Veins?

Following a physical examination, the doctor may prescribe the following tests to diagnose varicose veins:

  • An ultrasound is a non-invasive test, which is performed to check the flow of the blood.
  • venogram involves releasing a special dye into the veins and then taking an X-ray, which provides an overview of the blood flow.

What are the treatment options for varicose veins?

Varicose veins can be treated by certain medications, lifestyle changes and surgical procedures.

The lifestyle changes include:

  • Maintaining a healthy body weight
  • Exercising regularly to improve blood circulation
  • Avoiding standing for prolonged periods of time
  • Elevating or raising the legs while sleeping

Using compression socks or stockings can also help treat varicose veins.

Surgical procedures:

Surgery is opted when lifestyle changes are not effective in managing the symptoms of varicose veins. Most surgical procedures, including vein ligation and vein stripping, involve cutting and removing the affected part of the veins.

The other procedures performed to treat Varicose Veins include:

Endovenous ablation therapy, in which radiofrequency or heat radiation is used to block off the vein.

Sclerotherapy, wherein a chemical foam or liquid is injected into the vein that blocks the larger vein.

Microsclerotherapy, wherein a chemical foam or liquid is injected into the block of the smaller veins.

Laser therapy, in which Light Frequency Radiation is used to unblock the blocked vein.

Endoscopic Vein Surgery, in which a small lighted scope is inserted into the vein to block the vein, through a small incision.

What happens before the procedure?

Inform your healthcare provider about:

  • Onset and severity of pain and numbness (if any)
  • If you have any medical conditions
  • Any allergies or intolerances to certain medicines
  • Whether you are pregnant or think you may be pregnant
  • If you are breastfeeding
  • Medicines or supplements that you are taking including, blood thinners, over-the-counter medicines (aspirin or ibuprofen), herbs or vitamins
  • If you smoke or drink alcohol on a regular basis

Ask the doctor about:

  • What procedure would be best for your case
  • The possible outcomes of the treatment

Your healthcare team may give you guidelines for when to stop eating and drinking before the procedure. You may be asked to stop taking aspirin or other blood thinning agents at least one week before the procedure.

What happens during radiofrequency ablation?

Radiofrequency ablation is a procedure which uses radio waves to create heat and block the damaged vein.

The following are the steps involved in radiofrequency ablation procedure:

  • You will be asked to lie down on a hospital bed.
  • Imaging techniques like ultrasound will be used to guide the procedure.
  • The leg to be treated will be injected with a numbing medicine.
  • Once the leg is numb, a small hole is made in the vein using a needle.
  • The catheter is inserted into the vein.
  • When the catheter reaches the right position, it is slowly pulled backwards.
  • The catheter emits radio waves, and the vein is closed due to the heat generated.
  • Also, the other side branches may be removed or tied.
  • Then the catheter is removed, and pressure is applied to the insertion site to stop the bleeding.

The procedure takes about 45 to 60 minutes. You can go home on the same day.

What happens after the procedure?

You may experience pain, swelling, bruising, soreness and change in the colour of the treated area. Individuals treated for vein ligation and stripping may experience severe pain, infection, scarring and blood clots after the procedure. Seek immediate medical attention/care if the condition worsens.

After the procedure:

  • Take oral anti-coagulants for 3 months
  • Wear grade 2 elastic leg stockings for 3 months
  • Reduce weight

Long-term measures:

  • Use compression stockings throughout the day to squeeze the leg, thereby easing the blood flow through the veins and the muscles of the leg.
  • Elevate the feet while sleeping, which ensures a free back flow of the blood to the heart.

Call your healthcare provider if:

  • Fever of 100.4°F (38°C) or higher
  • Trouble breathing or chest pain
  • Signs of infection at the catheter insertion site, including redness, warmth, inflammation, increasing pain, bad-smelling discharge or bleeding
  • Numbness or tingling in the leg
  • Severe pain or inflammation

How to prevent the recurrence of varicose veins?

Individuals above fifty years of age are at an increased risk of recurrence of varicose veins within five years of having surgery. However, following a low-salt diet helps to prevent swelling and water retention in the limbs.

After the procedure, you may be asked to restrict doing strenuous activities. But prolonged inactivity may cause the formation of clots and pain. Therefore, following a regular exercise plan, as suggested by your doctor, helps to regain normalcy in the limbs and prevent recurrence of the varicose veins.




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Copyright © 2019, Dr. Raghu. All rights reserved.
Designed & Developed by R R Deepak Kambhampati.