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Behind the Scenes of Stent Placement: What Happens and Why
By Nancy Kennedy

Michael Mulock, M.D., an interventional cardiologist with Jefferson Cardiology Association, is one of the region’s most proficient practitioners of this exciting and often life changing subspecialty. Interventional cardiology focuses on minimally invasive diagnostic and therapeutic interventions to treat coronary artery disease as well as peripheral arterial disease that can cause poor circulation to the extremities. Using tiny, thin catheters, Dr. Mulock and his colleagues access the heart through the blood vessels in the wrist or groin to place a stent or perform diagnostic tests.

“Our therapies revolve around creating better blood flow to the heart and extremities. The process by which this happens is the same in the legs and the heart. When there is decreased blood flow to the leg muscles, the muscle can die, just as the heart muscle dies in a heart attack. Both are due to the buildup of cholesterol and plaque that can create blockages in the blood vessel,” Dr. Mulock explains.

For opening up the coronary arteries, interventional cardiologists now have drug-coated “stents” – tiny, open tubes like straws - which are especially good at keeping the artery open. In the past, the stent opened the artery but then as time passed, the stent itself became occluded. “We call that new blockage “re-stenosis” and it meant that patients often had to undergo a repeat procedure,” Dr. Mulock says. The design of the new drug coated stents borrows an idea from oncology: they have cancer medication in them that prevents new cells from growing and creating blockages.

They have proven to be very successful, as the re-stenosis rate is much lower now.

How do you know that you need a stent? An emergency stent placement can be lifesaving if you have a sudden heart attack, which indicates an acute closing off of a coronary artery.  A partial blockage in a coronary artery, causing insufficient blood flow to the heart muscle, will produce chest discomfort known as angina. A stent will improve the blood flow and relieve the pain. You may also need a stent if your heart muscle is not working well, and this can be determined by a stress test, cardiac ultrasound or a cardiac MRI. Sometimes, an EKG can reveal that an artery has closed off or is closing off.

For placement of a stent, the patient is awake but in a state of “twilight” or conscious sedation. The procedure takes place in the cardiac catheterization lab. Dr. Mulock makes a tiny puncture in the radial artery in the wrist, or in the femoral artery in the groin, and threads a catheter containing the stent through to the heart. Although the groin is the traditional site, he prefers the wrist’s radial artery when appropriate, because there is less risk of bleeding complications.

Dr. Mulock says that patients may need to stay overnight in the hospital, but those who have the wrist procedure are likely to go home within several hours. “When we place the stent through the radial artery, we remove the sheath of the catheter afterwards and put an inflated air-pressure wrist band on the site for 60-90 minutes to compress the artery and prevent bleeding. If you have the groin procedure, we use a closure device. It closes the hole in the femoral artery; the patient has to lay flat for two hours. This is because bleeding at the site is far more dangerous in the groin, where the artery is bigger.”

As with any such procedure, there are risks, although they are rare and preventive measures are taken. The worst risk is that the stent could clot and close up abruptly, causing a heart attack. Interventional cardiologists lower the risk of stent thrombosis by prescribing a blood thinner such as Plavix for at least six months to a year after the stent placement. Other risks include arrhythmia – an abnormal heart rhythm; a stroke; an adverse reaction to the contrast dye or sedative; and kidney damage from the dye, for persons with kidney disease. Almost always, the procedure goes smoothly.

Dr. Mulock graduated from Jefferson Medical College of Thomas Jefferson University and completed a residency in internal medicine at Cornell Medical Center followed by two fellowships at UPMC – one in cardiovascular medicine and one in interventional cardiology. He has been with Jefferson Cardiology Association since August.

Dr. Mulock is accepting new patients. To make an appointment, call (412) 469-1500. To learn more, visit www.jeffersoncardiology.com.

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