Saifudin Zukhri

Percutaneus yaitu prosedur memasukkan kateter kedalam

pembuluh darah melalui tusukan kecil di kulit.
Transluminal yaitu prosedur yang dilakukan di dalam pembuluh
darah.
Coronary yaitu pembuluh darah arteri di jantung.
Angioplasti yaitu tehnik membuka lumen pembuluh darah
dengan menggunakan balon.
PTCA adalah suatu prosedur terapi untuk memperbaiki aliran
darah ke miokard dengan menempatkan balon kateter pada
daerah penyempitan koroner dan mengembangkannya

Stent adalah alat yang ditanamkan pada pembuluh darah koroner

secara mekanis.PTCA dan stent adalah prosedur perkembangan
lanjut dari PTCA dengan menambahkan suatu alat di daerah
stenosis pada koroner untuk mempertahankan pembukaan
pembuluh darah koroner secara mekanis.
 Penyakit jantung koroner dengan bukti
iskemik.
Angina tidak stabil.

Infark miokard dengan hemodinamik

memburuk.
Kelainan Katub dengan CAD.

Primary PTCA pada IMA.

 The cardiovascular continuum of events

Ischemia = oxygen supply

and demand imbalance
Myocardial
Ischemia

CAD
plaque
Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
 The cardiovascular continuum of events

Coronary
Thrombosis

Myocardial
Ischemia

CAD

Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
 The cardiovascular continuum of events
ACS

Coronary
Thrombosis

Myocardial
Ischemia

CAD

Atherosclerosis

Risk Factors
( DYSLIPIDEMIA , BP, DM,
Insulin Resistance, Platelets,
Fibrinogen, etc)
Adapted from
Dzau et al. Am Heart J. 1991;121:1244-1263
Coronary
Plaque
Stable
UA/NSTEMI
STEMI
thrombosis
rupture
angina
 Penyempitan
Pembuluh darah
 Restenosis pada graft.
Penutupan mendadak dari diseksi sesudah
PTCA dan resiko untuk kolaps.
Restenosis setelah tindakan PTCA.
 Sebelum dilakukan tindakan PTCA dan stent dilakukan pemeriksaan koroner
angiografi untuk mengidentifikasi letak dan prosentase sumbatan arteri
koroner.
Setelah pasien diletakkan di meja khusus di ruang tindakan,dokter akan
menyuntikkan anestesi lokal pada pangkal paha atau radial dan menusukkan
jarum dan seath introduser dan kemudian memasukkan balon kateter melalui
arteri femoralis atau radialis hingga ke arteri koroner yang tersumbat.
Kemudian balon dikembangkan beberapa kali dengan tekanan
tertentu,dengan selalu memonitor proses pelebaran sumbatan dan keadaan
pasiennya.
Pengisian balon akan menekan plaque dinding arteri sekaligus membuka dan
melebarkan sumbatan.

Pada pemasangan stent maka dilakukan pengembangan balon beberapa kali

di daerah sumbatan,kemudian stent ditanam atau dipasang untuk
mempertahankan pembukaan arteri koroner yang cenderung restenosis.
 Kaji peengetahuan dan pemahman pasien dan keluarga tentang prosedur
PTCA
Berikan tambahan informasi bila diperlukan
Jelaskan bahwa pasien tetap sadar selama prosedur
Waktu pelaksanan 1-2 jam
akan merasakan sensasi hangat (hot flash) dan meta;ic taste saat injeksi
kontras
akan mengalami nadi cepat dan mungkin skipped pulses
Lakukan persiapan seperti mau operasi (bersihkan daerh yang mau
operasi,cukur rambut tempat injeksi bila perlu), informed concent.
Bila pasien dianatesi genral puasa
Berikan obat jantung sesuai perintah dengan sedikit air..
Kaji adanya riwayat alergi terhadap iodine , kontras atau makanan laut.
Catat data awal : VS, BB, TB,
Periksa nadi yang akan digunakan untuk akses : equality, amplitudo
Anjurkan untuk berkemih sebelum masuk ke ruang cath lab.
 Pasien biasanya di rawat di ICCU
Bedrest bebrapa jam dan tergantung pada perawat secar total
Penting untuk memberikan dukungan psikologis bagi pasien dan keluarga
Ketika pasien sampai di ruang rawat :
Pasang cardiac monitor untuk monitoring aritmia
Kaji adanya nyeri dada
Lakukan perekaman EKG 12 lead utk mengetahu iskemia/sumbatan stent
Monitor TD, nadi, respirassi setiap 30 menit dan suhu setia 4 jam.
Periksa ekstremitas yang digunakan untuk penusukan terhadap adanya gangguan
sirkulasi :
warna
Suhu
Nadi di bawah tempat insersi
Hematoma pada tempat insersi
.
Patients may experience pain from the puncture site and discomfort from their
prolonged period of immobility, so analgesia may be required.
 If a radial artery is used, the arterial sheaths are
removed in the cardiology laboratory and a specially
designed radial compression system is applied.
This remains in place for four hours.
After this time, if there is no evidence of haemorrhage,
a pressure bandage may be applied for 24 hours.
One advantage of using the radial artery is that the
patient can be nursed in a semi-recumbent position
immediately after the procedure and may get out of
bed after four hours, so minimising the risks involved
with remaining in bed.
Also, patients who have an elective procedure can be
managed as day cases.
 The femoral artery is a much deeper artery and haemostasis is
more difficult to achieve. If a femoral artery has been used, the
patient will still have a femoral artery sheath, and may also have a
venous sheath in place when returning to the ward.
These sheaths cannot be removed until the anticoagulant effects of
heparin given during the procedure have dissipated.
This may take up to six hours (Lilley and Aucker, 2001) and
clotting times will need to be monitored throughout this time.
The patient will need to remain in bed, lying flat, during this
period.
During PTCA, the patient will have received an intravenous bolus
dose of a glycoprotein IIb/IIIa (GPIIb /IIIa) inhibitor followed by
a maintenance infusion over 12 hours to reduce the risk of
intracoronary thrombus formation.
(When the radial approach is used, the GPIIb /IIIa inhibitor is
usually only prescribed to patients with unstable angina).
 GPIIb/IIIa inhibitors work by inhibiting platelet activity at the
injured atheromatous plaque by blocking the GPIIb/IIIa receptors
at the platelet surface membrane.
These drugs are very aggressive antithrombotic agents that can
cause severe bleeding. All potential bleeding sites will need to be
closely monitored, and the infusion itself will need to be managed
correctly.
Once the activated clotting time is within an acceptable range, the
arterial sheath may be removed by a doctor or nurse who has
received specific training in this procedure.
When the arterial sheath is removed from the artery, direct
pressure is applied until haemostasis is achieved. Pressure can be
applied manually or by the application of a compression device
designed for this purpose, for example, a Femstop.
After removal of the sheath, the nurse must carry out regular
observations of blood pressure, pulse, temperature and circulation
to the affected limb
 The patient should lie flat for two hours following
sheath removal (though this time limit may vary
according to local policy and consultant
preference) as movement could dislodge any
newly formed clots and cause bleeding (Botti et al,
2001).
The removal of the sheath and subsequent
pressure on the patients groin can activate the
parasympathetic nervous system, resulting in a
drop in the patients heart rate and blood pressure.
Therefore, 500mcg of atropine sulphate is needed if
these symptoms occur.
.
 The patient may be discharged home the day
after the procedure if he or she has had an
uneventful recovery and has a platelet count of
between 150x109/litre and 170x109/litre.
Discharge and ongoing care following PTCA -
The patient and his or her family should
receive written advice on what to do following
a PTCA and they should also be provided with
the telephone number of the cardiology ward
so that they have a point of contact
 Nurses should ensure the patient understands the
risks associated with coronary heart disease
(British Cardiac Society et al, 1998) and strategies
to reduce them. The patient should also know
about any prescribed medicines.
The patient requires a combination of 300mg of
aspirin and 75mg of clopidogrel for 28 days, which
has an antithrombotic effect. This is in addition to
any other cardiac drugs that he or she may be
prescribed. After 28 days, clopidogrel can be
discontinued and the aspirin dose reduced to
75mg daily. The patient will then be followed up
in the outpatients department