Spine Surgery Procedure at Indraprastha Apollo Hospitals Delhi, India

Electrophysiology (EP) Study

An Electrophysiologist is a trained cardiac specialist who would be performing an EP Study. This is a specialized procedure in which one or thinner, flexible wires, called catheters are inserted into a blood vessel (usually the groin) and guided into the heart. Each catheter has two or more electrodes to measure the heart's electrical signals as they travel from one chamber to another.

EP study or Electrophysiological study is mainly performed to diagnose cardiac rhythm abnormality, to help determine the best treatment, and to pinpoint the exact site where therapy may be useful.

CrossBoss Catheter

A decade ago, most of the patients with 100% blocked arteries were either managed medically or sent for surgery with long recovery times before they got back to their work. Today all these blocks can be cleared with latest advancements in angioplasty using advanced technologies that can be performed successfully in a few hours.

The CrossBoss Catheter is the latest technology introduced in India for the treatment of 100% blocked arteries. This catheter is made of a stainless steel braid and has a rounded tip that can be rotated in any direction. This facilitates the crossing of the 100% block, either through the tough lesions or can travel behind the blocked segment and exit beyond the lesion. At this point the next novel device called StingRay Balloon is used to get back into the actual passage of the blood vessel, using specialized wires.

Highlights of CrossBoss Catheter:

·         Minimally invasive

·         Faster recovery

·         Reduced hospital stay

·         Minimal blood loss

Along with minimal scarring and quicker recovery time, these newly introduced devices will add a new dimension to the treatment of chronic total occlusions (100% blocked arteries). This technology enhances the methods used by Japanese Cardiologists to open these blocked arteries and improves the clinical outcomes. For Cardiologists who are specialists in Chronic Total Occlusion (100% blocked arteries), this device is a great tool to have and will improve outcomes significantly. More such devices are expected in the future to treat such complex problems. This procedure requires a highly skilled intervention cardiologist with expertise along with excellent critical care staff in a tertiary care hospital set up like Apollo hospitals

Bioresorbable Vascular Scaffold (BVS)

The new Bioresorbable Vascular Scaffold (BVS), a non-metallic mesh tube that is used to treat a narrowed artery, is similar to a stent, but slowly dissolves once the blocked artery can function naturally again and stays open on its own. Similar to a small mesh tube, BVS is designed to help open up a blocked artery in the heart and restore blood flow to the heart muscle. BVS gradually dissolves once the artery can stay open on its own, potentially allowing the blood vessel to function naturally again.

Bioresorbable Vascular Scaffold is similar in appearance to a stent, but is a non-metallic, non-permanent, mesh implant which gets absorbed gradually, dissolves over time and allows the artery to function naturally again, similar to the way a cast supports a broken arm and is then removed. This new scaffold disappears over 12-24 months and supports the vessel until it has the ability and strength to stay open on its own.

BVS is made of a material commonly used in other medical devices, such as dissolving stitches. This material allows the BVS to break down into elements already found in your body like water (H2O) and carbon dioxide (CO2), enabling the artery to return to a more natural state.

BVS is the latest advance in treating Coronary Artery Disease.

Being treated with BVS means, you do not have a permanent implant which allows your artery to resume a more natural function. BVS may benefit you in the following ways.

·         Eliminates the concern about receiving a permanent implant.

·         Enables you to resume your everyday activities

·         May positively impact your long-term heart health

·         Helps to reduce your chance of future Coronary artery disease symptoms

Powerful blood thinners need not be given for a long time, and as the stent disappears, the normal vasomotor function (normal contraction and relaxation of the blood vessel) is restored. The vessel is brought back again to normal. It also helps in creating a normal vessel and if needed bypass grafts can be placed in that area in the future. Having an artery free of a permanent implant may mean more choices are available to find the best treatment in future if needed.

This technique is considered as the 4th revolution in Interventional Cardiology after the introduction of metallic drug eluting stents. The new BVS technique is everolimus-eluting and provides transient vessel support with drug-delivery capability, without the long-term limitations of the metal, presently in drug-eluting stents. This novel technology also overcomes many safety concerns associated with metal stent and possibly also has more clinical benefits.

This Procedure is performed at Apollo Hospitals making it one of the of the first to implant the commercially available BVS in India.

 

Bifurcation Stenting

Bifurcation lesion means there is a blockage in a site where the blood vessel divides into two and is more challenging to treat. Two branches of the blood vessel have narrowing. If a balloon angioplasty is performed in one, there are chances of the other branch closing. Conventionally one or two stents are placed and there are chances of recurrence in the side branch.

A new dedicated specially designed Nile Pax stent can be used to clear the blockage. This was done Apollo Hospitals to clear the blockage that was formed in the coronary artery involving two branches. The last patient was a diabetic lady with single vessel disease with a bifurcation lesion, a blockage in a site where the blood vessel divides into two affecting both branches. In such a case if a balloon angioplasty is performed in one, there are chances of the other branch closing, which would lead to further complications. Hence the advanced Nile Pax Stent (dedicated bifurcation stent) was used, which is shaped in such a way to remove narrowing from both the branches and has to be inserted through two wires to place it simultaneously in both branches.

This particular stent has several advantages. Stent covers both branches and is drug coated, helps in accessing both branches of the artery for future treatment if requited. Also the quantity of dye used and the duration of the procedure are much less.

These procedures are done through the hand approach and Nile Pax (Dedicated bifurcation stent) stent helped to complete the angioplasty within 40 minutes, thereby reducing the complications and the risk involved in the procedure ensuring quick recovery of the patient.

 

ClearWay™ RX - Rapid Exchange Therapeutic Perfusion Catheter

The ClearWay™ RX - Rapid Exchange Therapeutic Perfusion Catheter helps save larger area of heart muscle in heart attacks. Cardiac interventionists now know that it is not sufficient to remove the big clot that produces a heart attack; ensuring that the small vessels supply blood to the heart muscle is just as crucial.

When interventionists attempt to thrombolyse the clot that has triggered a heart attack, in most cases pieces of the blood clot travel down the micro vessels and get lodged there, cutting off supply to that portion of the heart muscle. If there is good micro-circulation, then there is no problem. But, in instances where there is improper flow of blood right to the end of the vessel, it has to be corrected. If we don't, then the amount of permanent damage will be higher.

Cardiologists operate with the aim of saving as much muscle as possible after a heart attack has occurred. In an acute myocardial infarction, there is interest only in the block that caused the attack, but once that has been thrombolised it is essential to check for the myocardial blush score - to see if the blood flow has been restored. The longer a blush lasts it means the block has not been successfully removed - that there may be blocks in the smaller vessels.

Through the traditional method of passing drugs through a catheter to bust those clots, it has been proven that over 50 per cent of the drug would be washed away and a further 20 to 25 per cent delivered to unwanted branches of the small vessels (that have no clots). In effect that means that less than 20 per cent of the drug will reach the target area.

So the idea is to use a device that will prevent the microvasculature from clogging. Apollo Hospitals uses a state-of-the-art therapeutic infusion device, the ClearWay catheter. It has a balloon at its end that gently weeps the drug into the targeted area, dissolving the clot. Typically such Occlusion Containment Infusion (OCI) equipment removes the occlusion (block) in the vessel. It contains the thrombus (clot) at the site itself and infuses the drug gently so that the clot dissolves. The prognosis for the patient is also better, and saves a larger area of the heart muscle.

 

Interventional Cardiology

The Interventional Cardiology Centres are manned by senior Cardiologists trained in India and abroad. Coronary stenting is routine and performed by most of the interventional cardiologists. Patients with high risk and multi vessel involvement are also treated.

Primary angioplasty, an approach of opening blocked coronary artery during acute myocardial infarction, in place of thrombolysis is practised in suitable cases. The cardiologists have performed over 85000 angiographies and over 50000 coronary angioplasties since the establishment of Interventional Cardiology Centres. Non-coronary intervention deals with a variety of cardiovascular abnormalities. Subclavian, iliac, femoral and carotid artery balloon angioplasty and stenting are being performed. Vascular dissection and aneurysm repair are also conducted with covered stents.

 

Beating Heart Surgery

Coronary Bypass Surgeries are performed using contemporary techniques including the off-pump bypass. Over 98% of the surgeries are "off-pump" or "beating heart" surgeries. During off-pump or beating heart surgery, the heart-lung machine is not used. The surgeon uses advanced operating equipment to stabilize (hold) portions of the heart and bypass the blocked artery in a highly controlled operative environment. Meanwhile, the rest of the heart keeps pumping and circulating blood to the body. This offers patients faster post-operative recovery and extracts less of a toll on their systems.

 

OCT Technique - Optical Coherence Tomography

OCT - Optical Coherence Tomography is a light based catheter which acquires on an image (photo) inside the heart blood vessel. OCT is a recently-developed, catheter-based Intravascular Imaging Technology that provides micron-scale resolution. It is a laser light equivalent of ultrasound imaging, measuring the intensity of backscattered infrared light rather than sound waves, and translates these optical echoes into a high-resolution, two-dimensional tomographic image. OCT has the highest imaging resolution of any currently-available technology. Cross-sectional resolutions of catheter-based OCT systems are in the range of 10-20 µm.

 

Fractional Flow Reserve (FFR)

Fractional Flow Reserve (FFR) is used to determine if a cardiac patient really needs a stent or by-pass surgery or can be kept only on medicines avoiding any procedure. This highly scientific and evidence based procedure is beneficial to the patient as FFR technology not only saves lives while avoiding unnecessary surgery but also helps patients to save cost. Fractional flow reserve - guided stent implantation has been established to be economically attractive in cost-effectiveness analysis.

Patients with heart disease have blockages in the blood vessels (arteries) of their heart. When these blockages limit the amount of blood able to flow through the artery, they are "hemodynamically significant" or "serious blocks." These "serious or tight" blockages often cause frightening symptoms such as chest discomfort or shortness of breath and can cause a heart attack. Blockages in blood vessels are identified during diagnostic Coronary Angiogram which forms the basis of most decisions whether the particular patient needs a stent or bypass or only medicines. This approach is perfectly reasonable when the Angiogram clearly demonstrates either a severely blocked blood vessel or a normal one. However, Angiography has well-known limitations and the significance of lesions of moderate severity is often difficult to determine based on just the Angiogram.

The blockages are often assessed visually and the narrowing is described as 50% or 90% depending on the visual severity of the narrowing. Most of the blocks above 70% are treated by stents or bypass surgery. But very often we come across blockages around 60% or 70% where the decision to treat by surgery or medicine is not clear. This uncertainty may result in inappropriate care with stenting of non- flow limiting lesions (non - serious) or failure to treat significant or serious blocks which can cause a heart attack.

Now with advances and availability of scientific data, Fractional Flow Reserve (FFR) procedure is done to measure how "tight or serious" a blockage is. The FFR is defined as the ratio between distal heart blood vessel pressure and aortic pressure, both measured simultaneously at maximal flow using a tiny coronary pressure guide wire. FFR is determined by a carefully calibrated sensor that measures the blood pressure upstream and downstream (before and after the block) after the administration of medicine like adenosine to induce maximum flow.
Fractional Flow Reserve is physiologically based and describes the ratio of the maximum achievable flow in the presence of a stenosis to the theoretical maximum flow in the same vessel in the absence of a stenosis. It takes into consideration the multiple, complex variables influencing coronary flow including lesion severity, lesion length and collateral flow.

Thus, if the FFR finds the difference between the two measurements is significant, then the blockage is considered to be significant. FFR has been shown to correlate very well with non-invasive stress testing and is considered to be complementary to a conventional Angiogram, particularly when the tightness of a blockage is difficult to establish by Angiography or when patients have not had non-invasive stress testing.

This procedure is performed at Apollo Hospitals.

Emergency Cardiac Surgery

Surgeries for treatment of complications caused by the dilatation of the aorta (aortic aneurysm), problems caused by irregular heart beat (arrhythmias - such as atrial fibrillation), heart failure, Marfan syndrome - a genetic disorder that causes cardiovascular abnormalities and other less common conditions are performed extensively.