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AORTIC STENTING

WHAT IS AORTA ?

Aorta is the large and major artery arising from the left heart otherwise called left ventricle,first courses up giving blood vessels to brain and both upper arms, arches down in the chest,travells down,pierces down the diapragm,become abdominal aorta, gives branches to all abdominal visera and end up dividing into two branches to lower limb vessels.

All blood vessels have a three layer wall, tunica adventitia, tunica media and tunica intima respectively from outside in. Arteries, arterioles , capillaries and veins have variations in their walls respective to their function. They are classified  as impedence vessels, resistance  vessels, exchange vessels and capacitance vessels.

DISSECTION  PATHOLOGY

DISSECTION PATHOLOGY

 Aorta is the impedence vessel as it has to withstand the tremendous kinetic energy  which it is imparted while getting ejected forcefully from the left ventricle. So unlike the other small vessels ,it is provided with much amount of elastin fibres in its tunica media. 

A combination of lifelong exposure to this kinetic energy and possible disruption of elastin architecture make it liable for meechanical dilatation which is called aneurysm.

A vessel is said to be aneurysmal if it gets dilated one and half times its original diameter.

X-RAY WITH STENTS

X-RAY WITH STENTS

WHAT IS AORTIC STENTING   ?

Stents are tubes of artificial matereal like polythene or polypropilene , reinforced with metal scaffold. They come in different diameter and lengths. In a stenotic vessel, after dilating the narrowed segment  with a balloon, to prevent recollapse a stent can be implanted.

In a dilated or dissected aortic segment, similarly a suitable sized stent can be implanted to exclude the dilated portion or to fix the dissected portion. These stents comes mounted on easy to use devices and can be introduced to the desired site through radial artery or through groin artery depending on its size. Once gets implanted , it gets endothelised in no time.

WHAT ARE THE STENTS AVAILABLE ?

Mainly two commercial entities market the commonly used stents.They are the multinationals Medtronic and Cooks. There is slight variations in their material selection and deployment devices. Each technology is patented by the respective companies.

WHAT ARE THE STENTS MADE UP OF  ?

Stents are made up of artificial matereals polyester or polyethilene reinforced by a metal scaffold usually Titanium or an alloy.

WHAT ARE THE COMPLICATIONS OF STENTING  ?

The most common and troublesome complication is called  Endovascular leak. Endo-vascular leak is collection of blood between the stent and the aortic wall. This may be due to inward filling from not so snug proximal or distal ends, Retrograde filling from a branch or oozing from the cloth used for the stent.

CT Scan-ABD-AORTIC-DISSECTION.

CT Scan-ABD-AORTIC-DISSECTION

In case of a significant endo-vascuar leak, balloon dilatation of proximal or distal ends, additional stenting, embolisation of collaterals,etc may be resorted to.

Stent migration is not a significant complication with new technologies.

Access related complications can arise if the vessels of introduction are atherosclerotic or damaged during the procedure.

SURGERY OR STENTING BETTER   ?

Stenting is less invasive , less painful, least blood loss, no chance of infection and gives comparble results. Surgery on the hands need a big cut on the body and its consequent chance of post-operative pain, chance of infection, possibility of blodd loss,etc.

However by surgery a near complete correction of the pathology can be affected.

However in certain situations, surgery is the only option.

WHAT ARE THE PREPARATIONS FOR STENTING  ?

  1. Before the operation , the condition of all organs has to assessed by available means.
  2.  For these a hemogram,renal funtion tests,kidney funtion tests,diabetic status, etc are ascertained.
  3. an,ecg,chest xray,ultrasonogram of abdomen,carotid dopplar , lung function tests, peripheral dopplar ,etc are mandatory.
  4. A CT scan may be considered.
  5. Spirometric excercises are used to assess and improve the lung function.
  6. 5 units of blood are arranged as a precaution. Generally one or sometime none are used.
  7. If any of the biochemical or imaging tests show any abnormality , corresponding speciality experts are consulted and suitable action followed.
  8. If the person is found to be very anxious or depressed, psychological support arranged.
  9. Familiarisation of the team members, hospital facilities, intensive care unit  and operationtheatre arranged.
  10. On the day prior to surgery the whole body is shaved and washed twice with an antibiotic solution.
  11. On the night prior to the surgery,the anesthetist will give a visit again and will brief about the operative procedure, later stay in the ICU,etc.He might instruct you rgarding when to take your dinner,etc
  12. Usually your operation is scheduled in the first half you will be asked not to take any food after 10 pm, take a wash next day mornig and not to take any food but the necessary medicines with a sip of water.
  13. If the operation is in the second half ,you may asked to take a light breakfast,the morning medicines and nothing after that.

WHO ALL WILL BE THERE IN YOUR AFTER CARE ?

After the heart operation a heat surgeon and heart anesthetist will be always by your side looking after you. You will be in the post-operative ICU, looked after by specialised nurses,respiratory physiotherapists,general physiotherapists,dieticians,pain specialists,etc.All your neds will be taken care off. During the three days of ICU stay,staff will give you body wash daily, brush your teeth, feed you,help you with passing urine and motion. The specialised nurses in the ICU will look after you just like their father or mother.

WHO ALL WILL BE THERE IN YOUR OPERATION?

There will be two cardiac surgeons, two specialised cardiac anesthetists, a person called perfusionist who run the heart lung machine, nurses and technician staff.

HOW WILL THE DAY OF OPERATION BE LIKE ?

If your operation is on the first half, you will be asked to get up around six in the morning,will be given an antibiotic wash, the necessary medicines with a sip of water and will be shifted to the operation theatre by 8 am. It is bit natural to feel bit anxious, but feel relaxed,the opeartion is only going to relieve you, you will not be allowed to feel any pain.

The nursing staff from ward will escort you to the operation theatre and then the operation theatre staff will care you after that. Always there will be a staff with you. You will be escorted to the operation theatre where you will be given an injection to go to sleep. From there on wards you will not feel anything.

WHAT IS DONE IN THIS OPERATION?

After putting you to sleep the doctors will take necessary IV lines, one wire into the artery of your hand or leg to accurately see your blood pressure continously, a wide IV line into your nack vein, a catheter in to your urinary blabber to pass urine, and finally a tube in to your wind pipe to give your breaths.. You will know none of these.

Through a small cut in the front of chest or right side of chest surgeons will see your heart and locate the place on aorta where exactly the cut has to be made. Once this done you will be connected to a heart lung machine, in order to stop your heart. Once heart is stopped,your aorta will opened,the disease aortic valve will be removed,the new valve will be sutured in, heart will be made to beat again,your cut will be closed and will be shifted to ICU,means intensive care unit.

HOW WILL BE THE ICU STAY?

While in the ICU ,you will slowly coming out of your sleep. When you come out of the sleep,might feel little bit of pain and discomfort, tubes coming from,hands,leg,urine,throat,etc.But please be reassured,all these are for your safety and one by one everything will be removed.

You might feel fresh and re -assured. Before the operation if you had some breathing difficulty,you might feel that after the operation it is much better.

Because of slight pain you might stiffen your neck,legs,chest,shoulder,etc. Try to keep all your muscles relaxed, that will reduce pain if you have any. Most but dont feel any pain,only a little bit of difficulty because of sitting in one position and a slight discomfort from the tubes and lines.

WHEN WILL ALL THE TUBES AND WIRES WILL BE REMOVED?

All those tubes are placed for your safety and wil be removed at the earliest. Out of all the tubes,the one in to your windpipe will be most hurting. The discomfort will be much less if you keep relaxed , all your muscles light,breath slowly.  Once you have recovered well from anesthesia and breathing well ,this tube will be removed at the earliest.

You may be on certain medicines to keep up your blood pressure and heart rate,once all those are settled,the wire in to your aretery of the hand or leg will be removed. May be by the second day,you will be made to sit on the chair beside and the catheter in to your urinary bladder will be removed.

WHEN WILL YOU BE SHIFTED TO ROOM FROM ICU?

Once your condition is stabilised, all the wires and tubes removed,you no more require oxygen,you can walk in the ICU,you will be shifted to theward. So far you were under the care of nurses and doctors  for 24hours.  Now you have recovered reasonably well from the operation and the resposibility of caring is being handed over to your relatives assisted by the ward nurses. Ward nurses may not be as experienced as the ICU nurses. The ICU nurses will teach your relatives and you what all have to be cared for . You also have to read through patient iformation booklet handed over to you.

WHAT ALL HAVE TO BE CARED WHILE IN THE WARD?

Unlike the abdominal operation, heart operation patients  dont have to rest in the bed always. If lie down in the bed ,there is more chance phlegm accumulation in the lung and more chance of pneumonia. May be take rest only few hours in the day time. Try to become more active. Do the incentive spirometry excercises every hour for ten times either ways, walk for 15 minutes every hour. Keep all muscles of the body relaxed all the time. Do excercises of the neck,shoulder, legs,ankle ,etc .

Little bit of breathlesness,mild pain, swelling of legs,loss of appetite,lack of sleep , constipation,etc are common after the operation. 

PREPARING TO GO HOME?

Say about 5 th day ,if most of your discomforts are better,if you can walk from one end of the verandha to the other and can climb the steps,you are ready to go home. The day prior to the discharge your blood will be tested for hemoglobin, kidney function and liver function,ECG,chest xray and echocardiogram.

If all these tests are also fine,you are ready to go home.

WHAT ALL HAVE TO BE CARED AT HOME?

You need to rest for another one or two weeks. Though the external wound has healed,inside wound is yet to be healed. For the first week keep youself to indoor,backyards or front verandha.Avoid relatives and small children. Continue to do breathing excercises, hand shoulder excercises, relaxation techniques and mild walking.

If you feel any discomfort, you are free to come to hospital at any time or feel free to contact any member of our team.

WHEN ARE THE FOLLOW UP VISITS?

Usually after the first week, you will be asked for the first visit just to see how you are progressing. You may be asked to bring your temperature chart,BPchart,pulse chart or sugar chart to monitor your progress.

If in this first visit ,if you are progressing well you will be scheduled for another visit after 2 weeks,when all blood examinations,chest xrays,echocardiogram,etc will be done. If all these examinations are normal,you will be advised to resume your duties.

Then you will have a follow up visit by the end of six months and then every year.