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Wednesday, December 5, 2012

DH's Coronary Total Occlusion (CTO) Procedure

DH's first stent was placed 10/18/12 in his left circumflex artery.  This was the artery that was 99% blocked.  He couldn't have the second stent placed in the right coronary artery that same day because two surgeons, or interventionalists as they are also called, had to be on duty, and the equipment was not advanced at the hospital where he had the first stent placed.  When he was sent to the hospital on the 18th, it was believed that he had two 70% occulded arteries, not one 100% blocked and the other 99% blocked, otherwise, he would have just been sent to the bigger hospital.  So we had to wait six weeks, and it was a very long wait.

We had been told because he had collateral circulation to this artery from the left anterior descending with blood flowing backward into the RCA, he could try and live without the stent, or a bypass, but we soon learned that that was a painful option as DH could not walk briskly without pain.  So, we decided to go ahead and have the CTO procedure done.  CTO stands for Chronic Total Occlusion, and these are tricky because sometimes the blockage can be as hard as a brickwall and cannot be broken through.

One day I looked through my husband's papers and one report said, "long, severe stenosis (hardening), in the right coronary artery, will attempt CTO".  Yikes.  My mind circled around "long, severe, stenosis".

I had read several articles on what it was like for surgeons to work through these long segments of hardening.  Because they can not see all of the artery due to the blockage, it is hard to tell how long the blockage is.  It could be 1/8 of an inch, or an inch, or unworkable along the whole artery.  From the angioplasty, to me it looked like DH'S was about 3/8 of an inch, but the surgeon said he couldn't tell for sure.

Guidewires are fed through two sheaths which are place through an incision in each groin which is about 1/4 of inch in diameter and stuck up into the femoral arteries of the groin about five inches.  These guide wires go up through the artery branches into the aorta and are fished up until they reach the blocked artery.  The doctors try to reach the blockage from both sides going through different arteries or the collaterals, whichever way they can, and try to route a hole all the way through the blockage.  This is like trying to drill a hole through a cement block in many cases, and if the doctor gets too aggressive, he can slip with the guidewire and puncture the artery.

Doctors try not to do this, and therefore, their efforts to be gentle, but still be able to break through, can make the procedure last hours.

I was very hopeful about the CTO procedure until last Thursday when the nurse at the catheterization lab called me with pre-op instructions.  I asked her how successful the procedure is, and she said, it was a procedure that was not attempted very often and that she couldn't give me a percentage of successful attempts.  "Sometimes they work, sometimes they don't", she said.  That sounded like about 50% to me.

I got online to see if I could find statistics and the best I could come up with was 70%.  That really depressed me, because what options would we have left if DH's CTO was not successful?  The two options we would have would be bypass surgery for a single artery, which I feel is a lot of invasion for one artery, and the other option was to try to just live with it, which to me is not an option when you have to live with pain daily.

Starting to realize the seriousness of our situation on a higher level, our family started to ask for prayers and fasting from our family and church members.  Having seen the report and the blockage myself, I was very concerned about our odds of having a successful outcome.

We are members of the Church of Jesus Christ of Latter-day Saints, and as soon as we started asking for prayers and fasting, we received confirmation from almost all of my family, my husband's family, and many of the members of our congregation that they would set aside Sunday, the day before the procedure, for a special fast for DH, and prayer.

At church on Sunday, the brother (we call each other brothers and sisters at church because we are all children of our Heavenly Father), gave the opening prayer to our Sunday service.  He said, "and bless those who will be having medical procedures that all will go well and that the surgeon's hands would be guided."

Clark and I felt the outpouring and concern that this brother had for us, and tears of gratitude streamed down our faces as we looked at each other.

After church, two other brethren gave Clark a blessing and asked in the blessing that he would be restored to full health and return quickly to be able to take care of his family and to be able to provide for them.  The blessing was so beautiful that I had been comforted that all would be okay.

As prayers and blessings were given, services were also offered.  One sister offered to sit with me at the hospital which I took her up on because of my experience when the last stent was placed.  During that last procedure, I cried a lot, and was very depressed, and I knew it would happen to me again.  I knew this would be a great inconvenience for her to sit with me, but also knew that I was very weakened from the stress of the last six weeks, because those six weeks were filled with constant worry and many sleepless nights. I knew my nerve reserves were very low, and that I could fall into a panic attack without another person with me.

 I rarely accept help from others.  I am quite self-reliant, but I have also learned that when help is offered, and you really need that help, that part of being self-reliant is being honest enough with yourself to accept that generously offered help, so as not to send yourself into a state that would make you more dependent.  I knew that if DH's procedure was not successful, I would have not been able to be strong for him, without some extra support.  Therefore, I am extremely grateful for this sister's offer, and it did prove to be very helpful.

We also had an offer for a meal on Monday evening.  I was also grateful for that offer too, and I was so grateful for the knowledge that my boys at home would not have to scrape for some dinner.

When we have a support network, we can get on our feet so much faster.  This is what I have learned, to be a part of that support network for others when the time comes, to pay forward the service that was rendered to me.

Monday morning we reported to the "cath lab", short for catheterization lab.  DH was taken to a little room, changed into a hospital gown, and then an I.V. was placed.  A medical history was taken, and then he was visited by the Xience rep who is a nurse that will be following him for the next five years for a study her company is doing on the their Xience stent.  They had a lot of blood drawn from him over the course of his stay.  I am glad he is part of the study because it will force us to have regular checkups over the next five years.  That kind of monitoring is comforting when you have had heart trouble in the past.

After that, the doctor came in and basically told us what I already knew, that his was an attempted procedure with no guarantees for success, with the risk of puncturing an artery, and to expect a very long wait, about 5 hours.

I ran out to tell my friend that she could go if she wanted because we were in for a very long day, and she said, "No, I've brought my knitting, I'm good, I'm staying."

Then we were told, he would be taken back in just a few minutes.  "Oh, wait, we have two acute cases that just came in from the E.R. and your doctor will be doing the surgery for one of them.  Looks like it will be another couple of hours, here's a coupon for the cafeteria to say we are sorry."

Well, I had prepared myself for that news too when I read the hospital's patient handbook on the "cath lab".

I want to emphasize in this post how important it is to one's sanity to read up on everything you can before going through procedures such as these so as not to have unexpected disappointments destroy your day.  If you go into the hospital knowing as much as you can about what could go wrong, you won't have to deal with the feelings of anger that could come from unexpected disappointments.

Sure we were disappointed when we found out there would be a two hours delay, but we were able to deal with it because we understood that some poor, unfortunately, person was already in surgery, who had dealt with a night of horrible pain and worry, and was going through a frightening procedure that they didn't know anything about, with a doctor they had never met, putting their lives in his hands.  We felt sorry for the two unfortunate fellows before us, and were glad that we were there in a scheduled manner, albeit, behind schedule, but still scheduled, and that we knew the competence of our doctor and trusted him, and were not in pain or panic.

Finally, at 11:30, three and a half hours after our appointment to start surgery, DH was wheeled into the OR.  I was able to follow him to the door and give him a hug and a kiss before he went in.  I hated that feeling, but it was better than the last time, because the last time, I didn't appreciate the seriousness of it, and just gave him a peck.  This time I savored him, and his spirit, and our kindredness for as long as I could, and it was nice not to regret being nonchalant during that moment of saying good-bye.

After saying good-bye, I took my seat in the waitng room next to my friend.  I felt so comforted having her there.  We have a lot in common and it was not hard to find things to talk about.  At one moment, I looked at the volunteer's desk and noticed another friend from church who was doing the same thing for another friend from church, sitting with her while she waiting for her mom to get done with her angioplasty.

I don't think it was an accident, or coicidence that the four of us found ourselves together to pass the time with each other.  We were a great comfort for each other and had a great visit.

The "cath lab" hands out pagers to the family members who wait for there loved ones.  They give them to them so that the loved ones can walk to the cafeteria, or walk to other places on the hospital campus because the wait can be so long.  I expected to be waiting for hours before my pager went off, but
to my great surprise, my pager went off 1 1/2 hours after DH was wheeled in.

I became concerned because it was so soon.  Did he go into a code blue?  Or is the doctor just wanting to give me a progress report?  The answer was neither.  The surgery was over!!!!  Wow!!!!  The surgery lasted 30 minutes.  DH was in there for 30 minutes before the procedure started.  The procedure last 30 minutes, and the recovery was 30 minutes.

I motioned my friend to follow me into the consultation room.  I recommend that anyone going through an angioplasty with their loved ones bring another person into the consultation room.  The first time, in October, I was so upset about the bad news that I didn't absorb anything the doctor had said, but luckily, my inspired son-in-law showed up just in time to go into the consultation room with me.  This time, I wanted someone with me too, so I had my friend come in with me.

I think it was fun for her to see my husband's heart pumping, and to see the video of the before and after pictures before stent and after stent.

Showing us the results, the doctor was very satisfied that DH had a very easy blockage to penetrate, and just caved when the catheter pushed against it and he didn't even have to use the guidewire to try and drill a hole through.  In addition, the second surgeon and the second catheter was never needed, although the incision had been made and the sheath had been placed.

When I got back into the "cath lab", the head nurse stopped me and congratulated me.  She said, "We have never had a CTO go so fast."  I said, "My husband used to be an LDS bishop.  He is loved by many people and many people were fasting and praying for him yesterday."  She pulled me close to her and whispered in my ear and said, "I believe in fasting and prayer and I know that is what made the difference for you husband. I believe it!"

DH's nurse, Patsy was also amazed at his speedy surgery.  We commented on how it was just as fast as the first procedure, and we told her about the fasting and prayer and she also bore her testimony that she knew that the prayers were the reason he had the outcome he did.

It was such a happy time.  When my friend and I first heard the news, I didn't know whether so bor leap for joy, but I ended up being reflective and quiet instead.  My friend gave me a big congratulatory hug, and I was glad that she had spent the day with me to be someone for me to share the joy with.

Moments like this are meant to be shared with someone.  It's like going on a thrill ride at a theme park. Who wants to sit by themselves?  It's twice as fun when you can scream and laugh your head off with someone else, and have that someone else to talk about it with later.  That was why she was supposed to be there with me that day.

While antioplasty is really quite easily tolerated for a patient, the recovery is quite difficult.

A bit of time after the procedure blood is drawn from the catheters and a drop is put on a monitor to see if the blood has thickened up enough to be able to pull the sheaths out.  While waiting for this to happen, the CTO patients can experience a lot of pain.  Regular antioplasty is not as painful because the sheaths placed in the groin and into the femoral artery are much smaller, but for CTO patients, the sheaths are big and can be felt into the abdomen, which for DH was very painful.  He was so relieved when the nurse said it was time to take them out.

However, he was not prepared for the pain that was to come.  Patsy was proactive and ordered vicodin, and morphine for DH to take just before taking the sheaths out so he could handle the pain.  But, even with the pain medications, the removal of the sheaths was more pain than he had ever experienced.  I went up to the head of the bed and stroked his hair, but he soon arched his back, clenched his fist and kicked his legs as they pulled out the first sheath.  His neck arteries were bulging and his face was very red.  It got to the point that I almost had to leave the room, but since he had been there for me for seven babies births, I stuck it out.

By the time the second sheath was pulled, the medication had become more effective, but he still had a really hard time with it.

After the sheaths are pulled out, the nurse has to put full pressure on the wounds for 15 to 30 minutes.  She places a dopplar radar microphone on the top of each foot so she can hear the pulse coming from the heart to the leg.  In this case, we don't want to hear a pulse.  As she is applying pressure to femoral artery in the groin, the goal is to cut off the blood flow enough to cause an occlusion to keep the patient from bleeding out of the incision.  The nurse should not hear any pulse from the dopplar radar.  This procedure is very labor intensive for the nurse, and all free nurses in the cath lab are accustomed to checking in to see if she needs a break.  In our case, we had two arteries that needed pressure, one in each groin side, so we had two nurses.

The other nurse, asked DH how long his procedure was and he said 30 minutes.  She declared, "praise God, he loves you!"  We told her about all of the fasting and praying that had been done for DH, and she said, "Praise, God, praise God!"

A couple days later we saw her at Walmart and I pointed at DH and said to her, "Look how well he is doing!"  She said, "He's the one with the prayers, right?"

DH's incisions occluded faster than they did the last procedure, and once the nurses were able to release pressure he felt a lot better.  It was then he became very hungry and very talkative, and we had the great blessing to have a couple hours alone together to be grateful for the wonderful events that had transpired that day.  What seemed would be a very trying day, turned out to be a beautiful day of feeling the Lord's love shine down upon us!

We also got some great tips from Kathy the patient tech that works in the cath lab.

1.  To train a dog, you need consistency.  Practice the behavior you want them to do, without a snack, but use a lot of animated praise, and do this 15 to 30 minutes daily.

2.  If you want to buy comfortable tennis shoes at a discount, if you wear lower than a size 9, which I do, then buy your shoes in the little girl's section.  I haven't bought new tennis shoes in 3 years.  It was time for me, so today I bought Nike's at Shoe Carnival from the little girl's section for $20.00, regularly $45.00, but of course it helped to have the second pair half off since I had to buy another pair for someone else in my family.  The same pair of shoes in the women's section was $70.00.  So, thank you to Kathy.

After our experience in the cath lab we were taken to a crowded and pooey smelling floor in the hospital where DH would spend the next 24 hours in a cramped and noisy hospital room.  I sat in the chair next to his bed, where I also slept for the night.

Our first experience with stent placement taught us that if you want to stay on a low-fat plant based diet, and eat their food, forget it.  I made bean burgers, and brought grapes and other fruits for DH to eat, and then he supplemented with side vegetables from the cafeteria.

The next 24 hours were uneventful, and typical of any hospital stay, being woke up every 2 hours for vitals, and waiting forever for the doctor to come and examine you so you could go home.  We could have been released at 9:00 a.m. as far as the nursing staff was concerned, but we had to wait for the doctor to finish his work for that day in the cath lab, so we spent 8 boring hours in the hospital.  Part of that time I took advantage of not having to be on-call for my kids and took a couple naps.

Since coming home DH has felt much better.  He has had a chance to test out his "new pipes".  So far, the only pain he has had are from the incisions.  He has had no chest pains whatsoever and he says his energy is much better than it has been in a long time!

How blessed we feel to have been candidates for the CTO recanalization or revascularization procedure.  Only 1 out of 10 people with totally occluded arteries are able to have this procedure done, and of those 1 out of 10, the odds of a successful outcome are between 50% and 70%.  Thirty percent of all people presenting to cath labs with blocked arteries have totally occluded arteries.  DH really fell into a low percentage of people who live in the shadows of a medical program that 1. thinks this procedure is worth tying up the cath lab for the extra two hours per procedure   2. and is willing to use their resources to train doctors for this very specialized skill set.  How blessed we are!  Had we lived in another city, he would have ended up with a very invasive surgery for one artery!!!!!

We were approached by Xience before the procedure to be a part of their study of their stent product.  We will not be compensated for our participation, but I am grateful to be a part of the study.  Because we are one of the few who were able to undergo an attempted CTO revascularization, I feel like we have been compensated.  The procedure will cost us and the hospital a fraction of what a bypass would have costs, and  DH still has all of his original arteries.

A bypass, when well taken care of will last 15 to 20 years.  I want my DH to be around as long as possible, and I didn't want him sentenced to another bypass 15 years for now, or death.  This is how our surgeon felt too, and I am so grateful to him for his perspective.  He could have made a lot more money filling up his time with bypasses, but instead he has spent his life perfecting angioplasty and CTO revascularization.
Dr. Marc A. Tannenbaum, you are the best!  Thank you again, and again, and again for revitalizing my husband and father of my many boys who can't wait to play a game of full court basketball with their Dad!!!!

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