Your use of the other site is subject to the terms of use and privacy statement on that site. It is possible that some of the products on the other site are not approved in your region or country. With an updated browser, you will have a better Medtronic website experience. Update my browser now. Designed to provide great conformability, control, and accuracy, the stent graft system offers a broad set of options to treat a wide range of patient anatomies.
The Heli-FX EndoAnchor system enhances durability to the level of a surgical anastomosis and addresses concerns for future complications. Most people who have angioplasty and stent placement are monitored overnight in the hospital. You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear your dentures or hearing aid if you use either of these.
If there is a lot of hair at the area of the catheter insertion often the groin area , the hair may be shaved off. An IV intravenous line will be started in your hand or arm before the procedure. It will be used for injection of medicine and to give IV fluids, if needed. You will be connected to an electrocardiogram ECG monitor that records the electrical activity of your heart and monitors your heart rate using electrodes that stick to your skin. Your vital signs heart rate, blood pressure, breathing rate, and oxygen level will be monitored during the procedure.
There will be several monitor screens in the room, showing your vital signs, the images of the catheter being moved through your body into your heart, and the structures of your heart as the dye is injected. You will get a sedative in your IV to help you relax. However, you will likely stay awake during the procedure. Your pulses below the catheter insertion site will be checked and marked so that the circulation to the limb below the site can easily be checked during and after the procedure.
Local anesthesia will be injected into the skin at the insertion site. This may be in your leg, arm, or wrist. You may feel some stinging at the site for a few seconds after the local anesthetic is injected. Once the local anesthesia has taken effect, a sheath, or introducer, will be put into the blood vessel often at the groin. This is a plastic tube through which the catheter will be threaded into the blood vessel and advanced into the heart.
The catheter will be threaded through the sheath into the blood vessel. The doctor will advance the catheter through the aorta into the heart. Fluoroscopy will be used to help see the catheter advance into the heart. The catheter will be threaded into the coronary arteries. Once the catheter is in place, contrast dye will be injected through the catheter into your coronary arteries in order to see the narrowed area s.
You may feel some effects when the contrast dye is injected into the IV line. These effects include a flushing sensation, a salty or metallic taste in the mouth, or a brief headache. These effects usually last only a few moments. Tell your doctor if you feel any breathing trouble, sweating, numbness, itching, nausea or vomiting, chills, or heart palpitations. After the contrast dye is injected, a series of rapid X-ray images of the heart and coronary arteries will be taken.
You may be asked to take in a deep breath and hold it for a few seconds during this time. When the doctor locates the narrowed artery, the catheter will be advanced to that location and the balloon will be inflated to open the artery. You may have some chest pain or discomfort at this point because the blood flow is temporarily blocked by the inflated balloon.
Any chest discomfort or pain should go away when the balloon is deflated. However, if you notice any continued discomfort or pain, such as chest pain, neck or jaw pain, back pain, arm pain, shortness of breath, or breathing trouble, tell your doctor right away. The doctor may inflate and deflate the balloon several times. The decision may be made at this point to put in a stent to keep the artery open.
In some cases, the stent may be put into the artery before the balloon is inflated. Then the inflation of the balloon will open the artery and fully expand the stent. The doctor will take measurements, pictures, or angiograms after the artery has been opened.
Once it has been determined that the artery is opened sufficiently, the catheter will be removed. The sheath or introducer is taken out and the insertion site may be closed with a closure device that uses collagen to seal the opening in the artery, by the use of sutures, or by applying manual pressure over the area to keep the blood vessel from bleeding.
Your doctor will decide which method is best for you. If a closure device is used, a sterile dressing will be applied to the site. If manual pressure is used, the doctor or an assistant will hold pressure on the insertion site so that a clot will form on the outside of the blood vessel to prevent bleeding.
Once the bleeding has stopped, a very tight bandage will be placed on the site. Staff will help you slide from the table onto a stretcher so that you can be taken to the recovery area. NOTE: If the insertion was in the groin, you will not be allowed to bend your leg for several hours. If the insertion site was in the arm, your arm will be kept elevated on pillows and kept straight by placing your arm in an arm guard a plastic arm board designed to immobilize the elbow joint.
In addition, a plastic band that works like a belt around the waist may be secured around your arm near the insertion site. The band will be loosened at given intervals and then removed when your doctor decides the pressure is no longer needed. After the procedure, you may be taken to the recovery room for observation or returned to your hospital room. You will stay flat in bed for several hours after the procedure.
A nurse will monitor your vital signs, the insertion site, and circulation and sensation in the affected leg or arm. Tell your nurse right away if you feel any chest pain or tightness, or any other pain, as well as any feelings of warmth, bleeding, or pain at the insertion site. Bed rest may vary from 2 to 6 hours depending on your specific condition.
If your doctor placed a closure device, your bed rest may be shorter. The stent has been outlined in a different shade of grey from the aorta. Note continued patency of the left subclavian artery. Recatheterisation was performed in seven patients after a median interval of In five patients, further balloon dilatation was performed with reduction of residual peak systolic pressure gradients from a mean of 15 mm Hg to a mean of 2 mm Hg, and three of these patients have since undergone spiral computed tomography with no evidence of aneurysm formation.
In one patient a gradient of only 6 mm Hg was found at recatheterisation and reintervention was not performed. The remaining patient, who had the aneurysm, has had two recatheterisations, at 9 months and 17 months after the second stent implantation.
On each occasion, the peak systolic gradient across the stented area was 35 mm Hg; however, as the aneurysm was still present, albeit small, no further intervention was performed. No patients had acute hypertensive crises immediately after stent implantation.
At the most recent follow up, eight patients were normotensive and were not receiving any treatment including two patients who had previously been treated with antihypertensive drugs. Eight patients were still on antihypertensive treatment, which consisted of one drug in five patients and a combination of drugs in three.
The choice of treatment of aortic coarctation and recoarctation is between balloon dilatation or surgery using several different techniques. Each type of treatment is associated with a variety of complications. On theoretical grounds, therefore, it was felt that stent implantation would avoid aneurysm formation. In our series, stent implantation has been shown to be effective in acutely reducing the pressure gradient, but it was still associated with aneurysm formation, albeit with a low incidence.
In hypertensive patients, the upper limb blood pressures are brought under control more easily, although continued antihypertensive treatment is often required. Follow up computed tomography showed continued patency of the stents, and no new aneurysm formation was noted even after redilatation of the stents.
In the rare clinical situation of aortic coarctation combined with aortic stenosis, treatment of the coarctation with stents may have an important role. In this, stent implantation avoids the operative hazards of treating both conditions surgically 21 and makes subsequent aortic valve surgery more straightforward.
We encountered a low incidence of complications at the level of vascular access. Patients who underwent a surgical approach from the carotid artery should have ultrasound angiography follow up of the cutdown site at a later date. We did not attempt to compare the results obtained with stent implantation with either surgery or balloon angioplasty techniques, in particular in the patients with aortic recoarctation. However, many of these patients had already undergone unsuccessful previous surgical or balloon angioplasty procedures.
Surgery in this situation may be technically more difficult, may often involve the use of patches or conduits, and runs a potential risk of causing compromise to the spinal blood supply. Surgical repair using synthetic patches is fraught with serious complications such as a high incidence of aneurysm formation and late death from aneurysm rupture. The mechanism of successful balloon dilatation of coarctation involves tearing of the aortic intima and media.
In vitro histological studies 23 , 24 and in vivo studies by intravascular ultrasound 25 , 26 have confirmed this mechanism. However, it is impossible to control the extent of tearing, which may extend transmurally. In addition, no safe upper limit has been defined for the required balloon diameter in relation to any aortic diameter measurement. Thus there will inevitably be a risk of aneurysm formation with balloon dilatation.
In contrast, during stent implantation it is not necessary to overdilate the coarcted segment to produce a good and predictable result. In addition the stent can buttress the aortic wall, thus preserving its integrity and preventing the extension of any tears that may be produced.
However, in spite of this, aneurysm formation was encountered in one patient who had an unusual long segment coarctation. It is possible that in this patient it resulted from overdilatation of the narrow segment from 2 mm to 12 mm. Following this complication in our series, we have modified our policy to adopt an approach of performing a staged dilatation. Thus the balloon is either not fully inflated to the diameter of adjacent measured normal vessel at the time of the stent implantation, or a smaller sized balloon is chosen.
If necessary a further dilatation is performed after six to 12 months in order to achieve complete expansion of the stent. In five of 17 patients in our study, redilatation of the stents was successfully achieved without any complications. If and when a significant aneurysm develops, a covered stent could be implanted.
We are aware of covered stents having been used in adult patients with abdominal aortic aneurysms 27 and thoracic aortic transection. Redilatation of stents in animal models of coarctation has produced conflicting results. Morrow et al re-expanded stents in five animals and noted compression of the media beneath the struts but no evidence of dissection of the intima or media.
Improvements in stent design including rounding of sharp edges or even the use of absorbable materials might further lower the risk of such transmural damage during both dilatation and redilatation.
The avoidance of predilatation with a balloon just before stent implantation may also reduce the risk of aortic damage. Successful balloon dilatation of both native 30 and recurrent coarctation 31 of the aorta can bring upper limb hypertension under control in the medium term, even in adult patients. In our series, the patients were often hypertensive before stent implantation in spite of combinations of antihypertensive drugs.
In the medium term, blood pressure has either normalised or has been easier to control with a more simplified drug regime. There is a theoretical concern that aortic stents may cause increased aortic wall impedance 32 and therefore systolic hypertension during exercise, but such a mechanism may occur in the post surgical aorta owing to scar formation or patch aortoplasty. One further theoretical concern might be the compromise of blood flow to small side branches arising from the aorta, particularly those supplying the spinal cord.
Continued patency of side branches in the coronary circulation has been demonstrated after stent implantation 33 and there have been no reports of spinal cord damage after aortic stent implantation thus far. Stent implantation for aortic recoarctation and native coarctation is successful in older children and adult patients and the acute results are encouraging.
Upper limb blood pressure can be brought under improved control although some patients continue to require antihypertensive treatment. Short term follow up shows continued relief of stenosis with a low incidence of complications but longer follow up is necessary. We thank Paul Summers for invaluable assistance in obtaining three dimensional reconstructions of spiral computed tomography images.
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