Percutaneous Interventions
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Percutaneous Interventions
Shannon Fogg, RN, MSNShannon Fogg, RN, MSN
Miya Purvis, RN, MSNMiya Purvis, RN, MSN
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ObjectivesObjectives
Differentiate various percutaneous Differentiate various percutaneous coronary and peripheral interventions.coronary and peripheral interventions.
Describe how to assess for and Describe how to assess for and manage complications of manage complications of percutaneous interventions. percutaneous interventions.
Discuss appropriate nursing Discuss appropriate nursing interventions related to post-interventions related to post-intervention care. intervention care.
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Cardiac AnatomyCardiac AnatomyReviewReview
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Cardiac AnatomyCardiac AnatomyReviewReview
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CAD- Coronary Artery CAD- Coronary Artery Disease Disease
CAD-Narrowing of small vessels- that CAD-Narrowing of small vessels- that supply blood to the heartsupply blood to the heart
Can be determined by:Can be determined by:– Exercise Stress TestExercise Stress Test– Nuclear ScanNuclear Scan– ECGECG– EchocardiogramEchocardiogram– Definitive test-Cardiac Cath LabDefinitive test-Cardiac Cath Lab
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CAD – Coronary Artery CAD – Coronary Artery DiseaseDisease
Healthy arteryHealthy artery Heart artery with Heart artery with
healthy blood flowhealthy blood flow Heart artery – Heart artery –
plaque that plaque that restricts blood flowrestricts blood flow
www.heartsurgeons.comwww.heartsurgeons.com
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Cardiac Catheterization Cardiac Catheterization Diagnostic procedure Diagnostic procedure
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Arterial Access sitesArterial Access sites
Common femoral arteryCommon femoral artery Radial arteryRadial artery Brachial arteryBrachial artery Axillary arteryAxillary artery Popliteal arteryPopliteal artery
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Radiopaque Contrast Radiopaque Contrast MaterialsMaterials
Used for imagingUsed for imaging Exposes Exposes
blockages or blockages or lesionslesions
May lead to acute May lead to acute renal renal insufficiency, insufficiency, prolonged prolonged hospital stays and hospital stays and even deatheven death
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Right Heart CatheterizationRight Heart Catheterization
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Left Heart CatheterizationLeft Heart Catheterization
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PCIPCI
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POBAPOBA
www.heartsurgeons.comwww.heartsurgeons.com
Insertion of Balloon
Inflated Balloon
Plaque against vessel wall, patent
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StentStent Scaffolding Scaffolding
placed into placed into vessel vessel
Pressed into Pressed into inner wall of inner wall of arteryartery
PermanentPermanent CoatingCoating Drug-elutingDrug-eluting
www.heartsurgeons.comwww.heartsurgeons.com
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AtherectomyAtherectomy
www.sutree.com/how-to/15755/Types-of-Atherectomy
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Other PCIsOther PCIs
BrachytherapyBrachytherapy Radiation therapyRadiation therapy Radiation source inside Radiation source inside
of or next to area of or next to area needing treatmentneeding treatment
Inhibit cell growth in Inhibit cell growth in responsible for responsible for restenosisrestenosis
Intravenous Intravenous Ultrasound Ultrasound (IVUS)(IVUS)
Technique for Technique for visualizing visualizing coronary arteries, coronary arteries, chambers, and chambers, and valvesvalves
Guided by catheterGuided by catheter May visualize May visualize
plaque that is not plaque that is not seen by seen by angiographyangiography
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Peripheral Vascular DiseasePeripheral Vascular Disease
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PTA – Percutaneous PTA – Percutaneous Transluminal AngioplastyTransluminal Angioplasty
Vessels of Upper and Lower Vessels of Upper and Lower extremitiesextremities– Carotid Carotid – Subclavian and BrachiocephalicSubclavian and Brachiocephalic– RenalRenal– IliacIliac– FemoropoplitealFemoropopliteal– TibioperonealTibioperoneal
Also known as PEI – Peripheral Also known as PEI – Peripheral Endovascular InterventionEndovascular Intervention
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Carotid StentsCarotid Stents
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Renal Artery StentsRenal Artery Stents
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Valvular DiseaseValvular Disease
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Valvuloplasty & Valve Valvuloplasty & Valve ReplacementReplacement
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Before the Lab
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Before the LabBefore the LabAssessmentsAssessments
NPO status Labs
Electrolytes Renal function
Allergies Meds
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InterventionsInterventionsPreparing Your PatientPreparing Your Patient
For NurseFor Nurse Inpatients ready at Inpatients ready at
5AM5AM Notify Notify physicianphysician of of
abnormalitiesabnormalities Complete pre-Complete pre-
procedure checklistprocedure checklist On-call On-call
medicationsmedications
For PatientFor Patient Focused assessment Focused assessment
(pulses, bruit)(pulses, bruit) Baseline 12-lead Baseline 12-lead
EKG (cardiac EKG (cardiac procedures)procedures)
Informed consentInformed consent Pre-procedure Pre-procedure
verificationverification Patient educationPatient education
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In the Lab
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After the LabAfter the Lab
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After the After the LabLab
H & PH & P Orders Orders Procedure log Procedure log
report report Cath lab Cath lab
summarysummary Cath Lab Cath Lab
nursing nursing documentationdocumentation
Where Do I Where Do I Look?Look?
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After the LabAfter the Lab
Vital signs Vital signs Pulse Pulse
assessmentassessment Groin Groin
assessmentassessment Telemetry/EKG Telemetry/EKG Labs Labs Pain rating Pain rating
and response and response to medicationsto medications
What Do I Look For?
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InterventionsInterventions Bedrest – HOB 45° or lessBedrest – HOB 45° or less Push oral fluids (avoid citrus)Push oral fluids (avoid citrus) IV fluidsIV fluids I & OI & O Resume medicationsResume medications Patient Education!Patient Education!
Post PCIPost PCI 12-Lead EKG12-Lead EKG ProB, CBC, Cardiac Enzymes 4hrs and 12 hrs postProB, CBC, Cardiac Enzymes 4hrs and 12 hrs post Repeat ProB if creatinine is elevatedRepeat ProB if creatinine is elevated
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Sheath Pulling-Manual Sheath Pulling-Manual CompressionCompression
Manual compression is the traditional Manual compression is the traditional method to achieve hemostasis.method to achieve hemostasis.
It is what all hemostatic devices are It is what all hemostatic devices are compared tocompared to
Correct technique is essential to stop Correct technique is essential to stop bleeding & minimize complications bleeding & minimize complications such as hematomas, such as hematomas, pseudeoaneurysms, etc.pseudeoaneurysms, etc.
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Manual Compression Manual Compression TechniqueTechnique
Distal pulses assessed prior to compressionDistal pulses assessed prior to compression Sterile gloves should be appliedSterile gloves should be applied Should hold two fingers above the puncture Should hold two fingers above the puncture
site and one finger on the top site prior to site and one finger on the top site prior to sheath/catheter removalsheath/catheter removal
Patient instructed to take a deep breath in & Patient instructed to take a deep breath in & exhale slowlyexhale slowly
As the patient exhales sheath/catheter should As the patient exhales sheath/catheter should be removed firm pressure should be appliedbe removed firm pressure should be applied
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Sheath Pulling InterventionsSheath Pulling Interventions ECG monitoring ECG monitoring
before and before and during removalduring removal
Watch HR and Watch HR and BP every 2.5 minBP every 2.5 min
IV access, IV access, atropine and NS atropine and NS availableavailable
Assess perfusion Assess perfusion before and after before and after pressure device pressure device in placein place
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Post Sheath Removal Post Sheath Removal InterventionsInterventions
Assess puncture site & distal pulses per Assess puncture site & distal pulses per hospital protocolhospital protocol
Pt should be instructed to:Pt should be instructed to:– Keep head down in order to avoid strain on Keep head down in order to avoid strain on
sitesite– Hold site if pt has to cough, sneeze, or laughHold site if pt has to cough, sneeze, or laugh– Keep affected leg straight & flatKeep affected leg straight & flat– Call nurse if feel anything warm & wet-have Call nurse if feel anything warm & wet-have
pt hold pressure at site until help arrivespt hold pressure at site until help arrives– HOB can be no greater than 30-45 degreesHOB can be no greater than 30-45 degrees
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Alternatives to Manual Alternatives to Manual CompressionCompression
FemostopFemostop Safe guardSafe guard These devices used to assist in These devices used to assist in
manual compressionmanual compression Placement and release of pressure of Placement and release of pressure of
these devicesthese devices These devices must be monitored These devices must be monitored
during their useduring their use
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FemostopFemostop Composed of plastic arch, inflatable Composed of plastic arch, inflatable
transparent dome, connection tubing, transparent dome, connection tubing, elastic belt, & hand held manometerelastic belt, & hand held manometer
Usually inflated 20 mmhg above Usually inflated 20 mmhg above systolic bpsystolic bp
Over 10-15 minutes pressure is Over 10-15 minutes pressure is decreased 20 mmhg every 2 minutes decreased 20 mmhg every 2 minutes until pressure releaseduntil pressure released
Pressure must be gradually releasedPressure must be gradually released
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SafeguardSafeguard
Composed of latex free sterile dressing, Composed of latex free sterile dressing, & inflatable bulb& inflatable bulb
Bulb provides constant pressure on Bulb provides constant pressure on puncture sitepuncture site
Placed on pt once hemostasis is Placed on pt once hemostasis is achievedachieved
Maximum inflation 50 ml of airMaximum inflation 50 ml of air Puncture site & distal pulses should be Puncture site & distal pulses should be
checked per hospital protocolchecked per hospital protocol
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TR BandTR Band
Plastic “bracelet” w/ dual balloons Plastic “bracelet” w/ dual balloons used to compress radial arteryused to compress radial artery
Air injected via injection port to apply Air injected via injection port to apply compression to radial arterycompression to radial artery
Must be sure to keep air syringe- will Must be sure to keep air syringe- will need it to remove airneed it to remove air
Must assess circulation of affected Must assess circulation of affected handhand
Release of pressure-usually 2-4 hrs or Release of pressure-usually 2-4 hrs or as ordered by MDas ordered by MD
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Closure DevicesClosure Devices
Angioseal-collagen plug inserted in Angioseal-collagen plug inserted in artery, reabsorbed in body in 90 daysartery, reabsorbed in body in 90 days
Mynx- extravascular plug-dissipates in Mynx- extravascular plug-dissipates in 30 days30 days
Perclose-suturing of arteryPerclose-suturing of artery Exoseal-Bioabsorbable plugExoseal-Bioabsorbable plug Reduces bedrest dramaticallyReduces bedrest dramatically Most patients can ambulate after 2 hrsMost patients can ambulate after 2 hrs
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ComplicationsComplications
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BleedingBleeding
Bleeding Bleeding – Manual pressure - 10 minutes (no Manual pressure - 10 minutes (no
peaking)peaking)– Page CV tech Page CV tech – Reapply dressingReapply dressing
GI bleedingGI bleeding HematuriaHematuria
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HematomaHematoma
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Retroperitoneal BleedRetroperitoneal Bleed
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Vasovagal SyncopeVasovagal Syncope
AssessmentAssessment Drop in HR Drop in HR
and/or BP and/or BP Feeling hotFeeling hot
NauseaNausea PallorPallor DiaphoresisDiaphoresis
InterventionsInterventions Atropine 0.5mg – Atropine 0.5mg –
1mg IVP1mg IVP Fluid bolus Fluid bolus
(watch EF)(watch EF) Hold/discontinue Hold/discontinue
nitratesnitrates ModifiedModified
trendelenbergtrendelenberg Check groin, H&HCheck groin, H&H
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Coronary Reocclusion or MICoronary Reocclusion or MI
AssessmentAssessment Chest pain – assess Chest pain – assess
PQRST PQRST Bruise pain?Bruise pain? Elevated cardiac Elevated cardiac
enzymesenzymes ST elevationST elevation
InterventionsInterventions Vital SignsVital Signs MONAMONA 12-Lead EKG12-Lead EKG Possible re-cathPossible re-cath Reassure patientReassure patient
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Cardiac TamponadeCardiac Tamponade
AssessmentAssessment Beck’s TriadBeck’s Triad Narrowing Narrowing
pulse pressurepulse pressure Tachycardia, Tachycardia,
dyspneadyspnea
TreatmentTreatment O2, fluidsO2, fluids EchocardiogramEchocardiogram Pericardial Pericardial
windowwindow PericardiocentesiPericardiocentesi
ss
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Contrast NephrotoxicityContrast Nephrotoxicity
Contrast-induced nephrotoxic effects Contrast-induced nephrotoxic effects – increase of > 0.5mg/dL in serum creatinine increase of > 0.5mg/dL in serum creatinine
within 48 hrs after contrast injectionwithin 48 hrs after contrast injection– 33rdrd leading cause of ARF in hospitalized leading cause of ARF in hospitalized
patientspatients Creatinine levels peak 4-5 days after Creatinine levels peak 4-5 days after
contrast, return to baseline contrast, return to baseline approximately 5 days after peak. Can approximately 5 days after peak. Can last up to 3 weekslast up to 3 weeks
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Other ComplicationsOther Complications
InfectionInfection Groin site painGroin site pain Vessel occlusion Vessel occlusion EmbolizationEmbolization
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DischargeDischarge
•Patient EducationPatient Education•Diagnoses and Diagnoses and Procedure type, Procedure type, locationlocation•Medications – Medications – Plavix Plavix every day!!every day!!•Diet and exerciseDiet and exercise•Smoking cessationSmoking cessation•Site careSite care
•Signs of infectionSigns of infection•BleedingBleeding
•When to call 911When to call 911•Follow-up appointmentFollow-up appointment•Contact information Contact information
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ReferencesReferences
Apple, S. & Lindsay, Jr. , J. (2000). Apple, S. & Lindsay, Jr. , J. (2000). Principles and Principles and practices of interventional cardiologypractices of interventional cardiology. . Philadelphia: LWW.Philadelphia: LWW.
Cardiovascular care made incredibly easyCardiovascular care made incredibly easy (2 (2ndnd ed.) ed.) (2009). Philadelphia: LWW.(2009). Philadelphia: LWW.
Morton, P.G. & Fontaine, D.K. (2009). Morton, P.G. & Fontaine, D.K. (2009). Critical care Critical care nursing: A holistic approach nursing: A holistic approach (9(9thth ed.). ed.). Philadelphia: LWW.Philadelphia: LWW.