Name of the Procedure:

Percutaneous Transluminal Revascularization of or through Coronary Artery Bypass Graft (internal mammary, free arterial, venous), including any combination of drug-eluting intracoronary stent, atherectomy, and angioplasty, with distal protection when performed (HCPCS: C9605). Commonly known as Coronary Artery Bypass Graft Revascularization or simply Percutaneous Coronary Intervention (PCI) for bypass grafts.

Summary

This medical procedure involves opening narrowed or blocked coronary artery bypass grafts using a combination of techniques such as stent placement, atherectomy (removal of plaque), and angioplasty (ballooning). It can also include the use of drug-eluting stents to keep the artery open and prevent further blockage.

Purpose

Medical Conditions or Problems:

• Coronary Artery Disease (CAD) that has led to the occlusion of coronary artery bypass grafts.

Goals or Expected Outcomes:

• Restore adequate blood flow to the heart muscle.
• Alleviate symptoms like chest pain (angina) and shortness of breath.
• Improve heart function and quality of life.
• Reduce the risk of heart attacks.

Indications

Symptoms or Conditions:

• Persistent chest pain (angina) not relieved by medication.
• Recurrence of symptoms after initial coronary artery bypass surgery.
• Evidence of graft blockage from diagnostic tests (e.g., angiography).

Patient Criteria:

• Patients with a history of coronary artery bypass graft (CABG) surgery.
• Those whose grafts have become narrowed or blocked over time.
• Patients who are at high risk or not candidates for repeat open-heart surgery.

Preparation

Pre-Procedure Instructions:

• Fasting for at least 6-8 hours before the procedure.
• Adjustments in medication, especially blood thinners, as advised by the doctor.

Diagnostic Tests or Assessments:

• Blood tests.
• Electrocardiogram (ECG).
• Echocardiogram or stress test.
• Coronary angiography to assess the condition of the grafts.

Procedure Description

Step-by-Step:

1. Anesthesia: Administration of local anesthesia and conscious sedation or general anesthesia as needed.
2. Access: Insertion of a catheter through the groin or wrist into the blood vessels.
3. Navigation: Guiding the catheter to the site of the blocked graft using X-ray imaging.
4. Treatment: Depending on the situation:
   • Atherectomy: Removal of plaque.
   • Angioplasty: Inflation of a balloon to open the artery.
   • Stent Placement: Deployment of a drug-eluting stent to keep the artery open.
5. Distal Protection Devices: Used to prevent debris from traveling downstream and causing new blockages.

Tools/Equipment:

• Catheters.
• Balloons.
• Stents (drug-eluting).
• Atherectomy devices.
• X-ray imaging equipment.

Anesthesia:

• Local anesthesia with sedation or general anesthesia, as appropriate.

Duration

Typically takes 1-3 hours, depending on the complexity of the case.

Setting

• Hospital cardiology department or specialized cardiac catheterization lab.

Personnel

• Interventional cardiologist.
• Cardiac nurses.
• Radiologic technologists.
• Anesthesiologist or nurse anesthetist, if general anesthesia is used.

Risks and Complications

Common Risks:

• Bleeding or bruising at the catheter insertion site.
• Blood vessel damage.
• Allergic reactions to contrast dye.

Rare Risks:

• Heart attack.
• Stroke.
• Arrhythmias (irregular heartbeats).
• Kidney damage from contrast dye.

Possible Complications:

• Acute closure of the treated artery.
• Infection.
• Need for emergency coronary artery bypass surgery.

Benefits

Expected Benefits:

• Relief from chest pain and other symptoms.
• Improved heart function.
• Enhanced quality of life.
• Prevention of future heart attacks.

Timeframe:

• Benefits are often realized immediately or within days after the procedure.

Recovery

Post-Procedure Care:

• Monitoring in a recovery area for several hours.
• Instructions on medication management.
• Hydration to help flush out contrast dye.
• Wound care at the catheter insertion site.

Expected Recovery Time:

• Most patients can return to normal activities within a week.
• Restrictions on heavy lifting and strenuous activity for a few days.

Follow-Up:

• Follow-up appointments with the cardiologist.
• Possible repeat imaging tests to assess graft patency.

Alternatives

Other Treatment Options:

• Medical management with medications.
• Repeat coronary artery bypass surgery.
• Enhanced external counterpulsation (EECP).

Pros and Cons:

• Medical management is less invasive but may not be as effective for severe blockages.
• Repeat surgery is more invasive with a longer recovery time but can address multiple blockages.
• EECP is non-invasive but suitable only for patients with chronic angina not responsive to other treatments.

Patient Experience

During the Procedure:

• Minimal to moderate discomfort at the catheter insertion site.
• A sensation of pressure or flushing when the dye is injected.

After the Procedure:

• Mild soreness at the access site.
• Possible fatigue for a few days.

Pain Management:

• Over-the-counter pain relievers for soreness.
• Specific instructions for any prescribed pain medication.

Comfort Measures:

• Comfort provided through sedation and local anesthesia during the procedure.
• Post-procedure care focused on pain relief and minimizing discomfort.