Stenting of the heart vessels: life after surgery, rehabilitation, nutrition and diet

One of the methods used in endovascular surgery to expand the lumen of the coronary arteries with their atherosclerotic stenosis or occlusion is the stenting of the heart, more precisely - the stenting of the heart vessels.

This is a revascularization of the myocardium by installing a special carcass inside the coronary arteries, a stent that is a cylindrical mesh structure made of biocompatible and non-corrosive metals, alloys or polymeric materials. Applying mechanical pressure to the vessel wall, the stent supports it, restoring the inner diameter of the vessel and hemodynamics. As a result, coronary blood flow is normalized and full myocardial trophism is ensured.

[1], [2], [3], [4]

Indications for the procedure

The main indications for this endovascular intervention are narrowing of the vessels due to atherosclerosis inherent in atheromatous deposits on their internal walls. This leads to insufficient supply of myocardium with blood and oxygen starvation of its cells (ischemia). To solve this problem, heart stenting is performed with ischemic disease and stable angina, arteriosclerosis of the coronary arteries of the heart, as well as in cases of atherosclerotic lesion of coronary vessels in systemic vasculitis. But stenting is carried out if the intensity of symptoms of ischemia is reduced with the help of drug therapy and the state can not be stabilized.

Carry out the coronary stenting of the heart vessels - that is, the stenting of the coronary arteries - to patients with a high risk of myocardial infarction. The intravascular stent can be implanted urgently: directly during an infarction (in the first few hours after its onset). And to minimize the likelihood of recurrent acute ischemia with the threat of cardiogenic shock and to restore the functions of the heart muscle, heart stenting is performed after a heart attack.

In addition, stenting is resorted to when a patient with a previously produced balloon angioplasty of the coronary artery or bypassing it again has a narrowing of the vessel.

As experts note, in cases of  coarctation of the aorta  (congenital heart disease), aortic stenting is performed even in infants.

[5], [6], [7], [8], [9], [10], [11]

Preparation

In the process of preparing for the stenting of the heart vessels, patients with appropriate diagnoses are given blood tests: clinical, biochemical, coagulogram; pass a roentgen of a thorax, an electrocardiography, US of heart.

To resolve the issue of the need for stenting, coronary angiography is mandatory  : according to the data of this survey, individual anatomical features of the cardiovascular system are revealed, the exact localization of the stenosis of the vessel and its degree are determined.

But without coronary radiography containing iodine, coronary angiography can not be performed, and this examination can give complications in the form of a reaction to a contrast agent (more than 10% of cases), cardiac arrhythmia and ventricular fibrillation with a fatal outcome (0.1% of cases).

It should be borne in mind that coronarography is not recommended for febrile conditions, if there is a history of hypertension, renal insufficiency, diabetes mellitus, hyperthyroidism, sickle cell anemia, myeloma, thrombocytosis or hypokalemia; this procedure is undesirable for the elderly.

In complicated cases, intravascular ultrasound is performed (visualizing the vessel wall and giving an idea of the size, quantity and morphology of atherosclerotic plaques) or optical coherence tomography.

Sometimes, most often in emergency situations, coronary angiography and stenting are carried out in the process of one manipulation. Then anticoagulants are injected intravenously before the operation.

[12], [13], [14], [15], [16], [17], [18]

Technique of the stenting of coronary vessels

Coronary balloon angioplasty and stenting of the heart vessels refer to percutaneous (percutaneous) coronary vascular dilatation with balloon catheter, and the stent installation in the lumen of the vessel actually occurs after its expansion by balloon angioplasty.

Usually the  technique of stenting of the heart vessels  - with the main stages of the process - is described in general terms as follows. After general sedation and local anesthesia of a small area of skin, the surgeon produces a puncture with simultaneous puncture of the vessel wall. Stenting of the heart vessels through the arm can be performed by transradial access (by puncture of the radial artery of the forearm), and also through the femoral artery in the groin area (transfemoral access). The whole procedure is performed with fluoroscopic visualization by an angiograph with the introduction of a contrast agent into the blood.

Through a puncture in the vessel, a catheter is inserted into the arterial channel - to the mouth of the coronary vessel, in which stenosis is revealed. Then the conductor is introduced, along which the catheter with the can and the stent attached to it is advanced; as soon as the balloon is exactly at the point of constriction, it is inflated, causing the walls of the vessel to expand. In this case, the stent is straightened and under the pressure of the balloon it fits tightly to the endothelium, pressing into the vascular walls and forming a strong framework, which becomes an obstacle to the narrowing of the lumen.

After removing all the accessories, the site of the puncture of the vessel is treated with antiseptics and covered with a pressure bandage. The entire process of coronary stenting of the heart vessels can last from one and a half to three hours.

Contraindications to the procedure

Coronary stenting of the heart vessels is contraindicated when:

• acute violation of cerebral circulation (stroke);
• diffuse cardiosclerosis;
• congestive (decompensated) heart failure of various etiology (coronary insufficiency of metabolic origin);
• presence of acute infectious diseases, including bacterial endocarditis;
• severe functional insufficiency of the liver, kidneys or lungs;

In the case of local internal bleeding and patients with coagulation disorders, the stent installation is also contraindicated.

Do not perform myocardial revascularization by stenting:

• if the patient does not tolerate iodine, and the products containing it cause allergies;
• when the lumen of the coronary arteries is narrowed by less than half, and the degree of hemodynamic disturbances is negligible;
• in the presence of extensive diffuse stenoses in one vessel;
• if narrowed heart vessels of small diameter are narrowed (usually these are intermediate arteries or distal branches of the coronary arteries).

There are risks of stenting of the heart vessels, which are associated with damage to the vascular wall, infection, incorrect stent implantation, the development of a heart attack and cardiac arrest.

Experts emphasize the risk of developing an allergic or anaphylactoid reaction (reaching shock) on iodine-containing radiopaque agents injected into the blood during stenting. This increases the level of sodium and glucose in the blood, causing its hyperosmolarity and thickening, which can trigger vascular thrombosis. In addition, these substances have a toxic effect on the kidneys.

All these factors are taken into account by cardiologists, when a patient with coronary circulation disorders is offered a stent installation. However, you should consult with specialists in vascular surgery. Where can I get advice on stenting the heart? In regional clinical hospitals, many of which (for example, in Kiev, Dnipro, Lviv, Kharkov, Zaporozhye, Odessa, Cherkassy) have cardiosurgical centers or departments of endovascular surgery; in specialized medical centers of vascular and cardiac surgery, the largest of which is the Heart Institute of the Ministry of Health of Ukraine and the National Institute of Cardiovascular Surgery. N. Amosova.

[19], [20], [21]

Consequences after the procedure

Possible complications after the procedure include:

• formation in the area of the puncture of the vessel of the hematoma;
• bleeding after removal of the catheter from the artery - in the first 12-15 hours after stent placement (according to some data, in 0.2-6% of patients);
• temporary, within the first 48 hours, heart rhythm disturbance (more than 80% of cases);
• dissection of the intima (inner shell) of the vessel;
• severe renal failure.

The fatal consequences after the procedure are associated with the development of myocardial infarction (statistics vary in different sources from 0.1 to 3.7% of cases).

One of the key complications of stenting is  restenosis, that is, repeated narrowing of the lumen several months after the coronary intervention; is observed in 18-25% of cases, and according to the information of the experts of the American Society for Cardiovascular Angiography and Interventions - more than a third of patients.

This is due to the fact that after the stent is installed - due to its pressure on the vessel wall and the development of an inflammatory reaction - blood platelets may accumulate and accumulate on the inner surface of the structure , causing thrombus formation -  stent thrombosis, and endothelial cell hyperplasia leads to intima fibrosis.

As a result, patients develop shortness of breath after stenting the blood vessels of the heart, a feeling of pressure and compression behind the sternum. According to clinical statistics, approximately 26% of patients have tingling and pain in the heart after stenting, which indicates a recurrent angina. In such situations, given the high risk of developing myocardial ischemia, which is easily transformed into a heart attack, reentrant cardiac vascular stenting or bypass surgery is recommended. What is best for a particular patient, cardiologists decide after ultrasound or CT of the heart.

What is the difference between shunting and heart stenting? Unlike stenting, aortocoronary shunting is a full cardiosurgical intervention under general anesthesia with thoracic access (chest opening). During the operation, part of another vessel (extracted from the internal thoracic artery or femoral saphenous vein) is taken and an anamistosis is formed from it, bypassing the narrowed portion of the coronary vessel.

To avoid thrombosis and restenosis, stents with various antithrombotic passive coatings (heparin, nano-carbon, carbide-silicon, phosphorylcholine), as well as eluting stents (drug-eluting stents) with active coating containing slowly washed preparations (groups of immunosuppressors or cytostatics). Clinical studies have shown that the risk of re-stenosis after implantation of such structures is significantly reduced (to 4.5-7.5%).

To prevent thrombosis of blood vessels, all patients should take a long time to take medications after stenting the blood vessels of the heart:

• Aspirin (acetylsalicylic acid);
• Clopidogrel, other trade names - Plagril, Lopyrel, Trombonet, Zilt or Plavix after stenting the heart vessels;
• Tikagrelor (Brilinta).

Postoperative period

In the early postoperative period, which includes stay in the hospital for two to three days (in some medical institutions a little longer), patients should follow bed rest after 10-12 hours after stenting the heart vessels.

By the end of the first day, if the patient feels normal after stenting the heart vessels in patients, they can walk, but the first two weeks of physical activity should be as limited as possible. A sick leave sheet is required after stenting the heart vessels.

Patients are warned that it is impossible after the stenting of the heart vessels to take a hot shower or bath, lift weights, and also strictly forbid smoking after stenting the heart vessels.

It should be borne in mind that the temperature after stenting of the heart vessels may slightly increase due to the introduction of heparin half an hour before the start of the operation (it is used to minimize the risk of blood clots). But the febrile state can also be associated with infection when the catheter is inserted.

High blood pressure after stenting of the heart vessels is noted, especially in patients with arterial hypertension: in fact, the installation of a stent in a coronary vessel does not solve the problems with arterial pressure and atherosclerosis. AD fluctuations after stenting are also explained by vagal vascular reactions mediated by thyroxin: iodine-containing radiopaque agents increase the level of this hormone of the thyroid gland in the blood, and acetylsalicylic acid (Aspirin) prescribed in high doses reduces.

Transient reduction in vascular tone and low blood pressure after stenting of the heart vessels can also be one of the  side effects of contrast agents containing iodine. In addition, a negative factor is the effect on the body of X-ray irradiation, the average dose of which during the installation of coronary stents ranges from 2 to 15 mSv.

[22], [23], [24]

Rehabilitation and recovery

How long cardiac rehabilitation and recovery after intravascular stent placement takes place depends on many factors.

First of all, it is necessary to follow all medical recommendations conscientiously after stenting the heart vessels.

In particular, moderate exercise and gymnastics after heart stenting should become an integral part of the way of life. Experts argue that aerobic exercises are best suited - in the form of regular walks on foot or by bicycle, which do not require special efforts, but strain most muscles and promote blood circulation. Only need to monitor the state of the pulse and prevent tachycardia.

Fans in the bathhouse will have to settle for a shower in their bathroom. Usual motorists need to refrain from driving for two to three months. And if the stent was implanted with exacerbation of the coronary syndrome, the threat of a heart attack or during it, it is unlikely that the stress-related work by the driver after the stenting of the heart vessels will be possible. Just in such cases, a disability can be established after stenting the heart.

Do I need a diet after heart stenting? Yes, since it is not allowed to increase the level of cholesterol in the blood, and lifelong restrictions in the diet should touch the total calorie (in the direction of its decrease, to avoid obesity), as well as the consumption of animal fats, table salt and fermented products. About what you can eat after stenting at the heart, for more details read in the publication -  Diet with increased cholesterol  and article -  Diet for atherosclerosis

The ban on smoking was discussed above, but alcohol after stenting the heart vessels - only quality red wine (dry), and only one glass - occasionally it is possible.

In the first four to five months, sex after cardiac stenting, cardiologists are equated with strong physical stress, so it must be taken into account not to overdo it and cause a heart attack.

In the case of a severe attack, when the chest pain does not remove nitroglycerin, how to behave after stenting the heart vessels? Call an ambulance, and better cardiac!

In addition, daily taken Clopidogrel (Plavix) reduces platelet aggregation, that is, stop any random bleeding will be difficult, and this should be taken into account by all patients. Other side effects of this drug: increased bleeding and bleeding (nasal, gastric); cerebral hemorrhage; problems with digestion; headaches, joint and muscle pain.

In general, despite this, pains in the heart stop in seven cases out of ten, and patients with a coronary stent feel much better.

Lifestyle after heart stenting

According to experts in the field of endovascular surgery, as well as testimonials of patients about stenting of the coronary vessels,  life after heart stenting  changes for the better.

When doctors are asked how many people live after stenting the heart, they leave a direct answer: even with irreproachably performed endovascular intervention, there are many factors (including immune ones) that somehow affect the state of the general and coronary circulation.

But if you lead a healthy lifestyle after stenting the heart, it will last longer and will allow you to live up to a decade and a half.