Angioplasty and Stenting

Angioplasty is a process to re-open or enlarge blood vessels that are closed or occluded. It may involve one of several techniques including expanding a small balloon in the vessel, injecting agents to dissolve clots, or inserting a metal device called a stent to keep the vessel open.

Basic Facts
• Coronary angioplasty is a medical procedure in which a balloon is used to open a blockage in a coronary (heart) artery narrowed by atherosclerosis. This procedure improves blood flow to the heart.
• Atherosclerosis is a condition in which a material called plaque builds up on the inner walls of the arteries. When atherosclerosis affects the coronary arteries, the condition is called coronary artery disease (CAD).
• Angioplasty can improve some of the symptoms of CAD, such as angina (chest pain) and shortness of breath. It also can reduce damage to the heart muscle from a heart attack and reduce the risk of death in some patients.
• You may need angioplasty if medicines and lifestyle changes haven't improved your symptoms of CAD. You also may need angioplasty as emergency treatment during a heart attack.
• Angioplasty is less invasive than surgery. General anesthesia isn't needed. You will be given medicines to help you relax, but you will be awake during the procedure.
• Angioplasty is performed in a special part of the hospital called the cardiac catheterization laboratory.
• Before angioplasty is done, your doctor will need to know whether your coronary arteries are blocked. To find out, he or she will do an angiogram and take an x-ray picture of your arteries to show any blockages and where they're located. Once your doctor has this information, the angioplasty can proceed.
• During angioplasty, your doctor will use a small tube called a catheter with a balloon at the end. He or she will thread the balloon through an artery to the blockage. The balloon is blown up (inflated), pushing the plaque outward against the artery wall. This opens the artery more and improves blood flow through it.
• During angioplasty, a stent (mesh tube) is often placed in the artery that has been opened. The stent reduces the chance that the artery will become blocked again in the future. The stent remains in place after the procedure.
• Most people go home 1 to 2 days after having angioplasty. Full recovery from the procedure is usually 1 week or less.
• Lifestyles changes are recommended after angioplasty to improve CAD and to prevent the arteries from becoming narrowed or blocked again. Lifestyle changes include a healthy diet, weight control, medicines to lower high blood pressure and high blood cholesterol, regular physical activity, and quitting smoking.
• Angioplasty is a common medical procedure and is generally safe, but there is a small risk of serious complications.
• Renarrowing of the treated artery and growth of scar tissue within a stent can occur. The use of medicine-coated stents can lower the chance of this happening, but these stents aren't without risk. In some cases, blood clots can form in the medicine-coated stents.
• Research on angioplasty is ongoing to make it safer and more effective, to prevent treated arteries from closing again, and to make the procedure an option for more people.

Who Needs Coronary Angioplasty?

Coronary angioplasty is used to restore blood flow to the heart when the coronary arteries have become narrowed or blocked due to coronary artery disease (CAD).

When medicines and lifestyle changes, such as following a healthy diet, quitting smoking, and getting more physical activity, don't improve your CAD symptoms, your doctor will talk to you about other treatment options. These options include angioplasty and coronary artery bypass grafting (CABG), a type of open-heart surgery.

Your doctor will take into account a number of factors when recommending the best procedure for you. These factors include how severe your blockages are, where they're located, and other diseases you may have.
Angioplasty is often used when there is less severe narrowing or blockage in your arteries, and when the blockage can be reached during the procedure.

CABG might be chosen if you have severe heart disease, multiple arteries that are blocked, or if you have diabetes or heart failure.

Advantages of angioplasty over CABG:
• Fewer risks than CABG.
• Angioplasty is not surgery, so it won't require a large cut.
• Is done with medicines that numb you and help you relax. Unlike CABG, you won't be put to sleep for a short time.
• Has a much shorter recovery time.
Angioplasty also is used as an emergency procedure during a heart attack. As plaque builds up in the coronary arteries, it can burst, causing a blood clot to form on its surface. If the clot becomes large enough, it can mostly or completely block blood flow to part of the heart muscle.

Quickly opening a blockage lessens the damage to the heart during a heart attack and restores blood flow to the heart muscle. Angioplasty can quickly open the artery and is the best approach during a heart attack.

A disadvantage of angioplasty when compared with CABG is that the artery may narrow again over time. The chance of this happening is lower when stents are used, especially medicine-coated stents. However, these stents aren't without risk. In some cases, blood clots can form in the medicine-coated stents and cause a heart attack. Your doctor will discuss with you the treatment options and which procedure is best for you.

What To Expect Before Coronary Angioplasty
Meeting With Your Doctor
A cardiologist performs coronary angioplasty at a hospital. If your angioplasty isn't done as emergency treatment, you'll meet with your cardiologist before the procedure. Your doctor will go over your medical history (including the medicines you take), do a physical exam, and talk about the procedure with you. Your doctor also will order some routine tests, including:
• Blood tests
• An EKG (electrocardiogram)
• A chest x ray
When the procedure is scheduled, you will be advised:
• When to begin fasting (not eating or drinking) before the procedure. Often you have to stop eating or drinking by midnight the night before the procedure.
• What medicines you should and shouldn't take on the day of the angioplasty.
• When to arrive at the hospital and where to go.
Even though angioplasty takes 1 to 2 hours, you will likely need to stay in the hospital overnight. In some cases, you will need to stay in the hospital longer. Your doctor may advise you not to drive for a certain amount of time after the procedure, so you may have to arrange for a ride home.

What To Expect During Coronary Angioplasty

Coronary angioplasty is performed in a special part of the hospital called the cardiac catheterization laboratory. The "cath lab" has special video screens and x-ray machines. Your doctor uses this equipment to see enlarged pictures of the blocked areas in your coronary arteries.
Preparation
In the cath lab, you will lie on a table. An intravenous (IV) line will be placed in your arm to give you fluids and medicines. The medicines will relax you and prevent blood clots from forming. These medicines may make you feel sleepy or as though you're floating or numb.

To prepare for the procedure:
• The area where the catheter will be inserted, usually the arm or groin (upper thigh), will be shaved.
• The shaved area will be cleaned to make it germ free and then numbed. The numbing medicine may sting as it's going in.
Steps in Angioplasty
When you're comfortable, the doctor will begin the procedure. You will be awake but sleepy.
A small cut is made in your arm or groin into which a tube called a sheath is put. The doctor then threads a very thin guide wire through the artery in your arm or groin toward the area of the coronary artery that's blocked.
Your doctor puts a long, thin, flexible tube called a catheter through the sheath and slides it over the guide wire and up to the heart. Your doctor moves the catheter into the coronary artery to the blockage. He or she takes out the guide wire once the catheter is in the right spot.
A small amount of dye may be injected through the catheter into the bloodstream to help show the blockage on x ray. This x-ray picture of the heart is called an angiogram.
Next, your doctor slides a tube with a small deflated balloon inside it through the catheter and into the coronary artery where the blockage is.
When the tube reaches the blockage, the balloon is inflated. The balloon pushes the plaque against the wall of the artery and widens it. This helps to increase the flow of blood to the heart.
The balloon is then deflated. Sometimes the balloon is inflated and deflated more than once to widen the artery. Afterward, the balloon and tube are removed.
In some cases, plaque is removed during angioplasty. A catheter with a rotating shaver on its tip is inserted into the artery to cut away hard plaque. Lasers also may be used to dissolve or break up the plaque.
If your doctor needs to put a stent (small mesh tube) in your artery, another tube with a balloon will be threaded through your artery. A stent is wrapped around the balloon. Your doctor will inflate the balloon, which will cause the stent to expand against the wall of the artery. The balloon is then deflated and pulled out of the artery with the tube. The stent stays in the artery.
After the angioplasty is done, your doctor pulls back the catheter and removes it and the sheath. The hole in the artery is either sealed with a special device, or pressure is put on it until the blood vessel seals.
During angioplasty, strong antiplatelet medicines are given through the IV to prevent blood clots from forming in the artery or on the stent. These medicines help thin your blood. They're usually started just before the angioplasty and may continue for 12–24 hours afterward.

What To Expect After Coronary Angioplasty

After coronary angioplasty, you will be moved to a special care unit, where you will stay for a few hours or overnight. While you recover in this area, you must lie still for a few hours to allow the blood vessels in your arm or groin (upper thigh) to seal completely.
While you recover, nurses will check your heart rate and blood pressure. They also will check your arm or groin for bleeding. After a few hours, you will be able to walk with help.
The place where the tube was inserted may feel sore or tender for about a week.
Going Home
Most people go home 1 to 2 days after the procedure. When your doctor thinks you're ready to leave the hospital, you will get instructions to follow at home, including:
• How much activity or exercise you can do.
• When you should follow up with your doctor.
• What medicines you should take.
• What you should look for daily when checking for signs of infection around the area where the tube was inserted. Signs of infection may include redness, swelling, or drainage.
• When you should call your doctor. For example, you may need to call if you have a fever or signs of infection, pain or bleeding where the catheter was inserted, or shortness of breath.
• When you should call 9–1–1 (for example, if you have any chest pain).
Your doctor will prescribe medicine to prevent blood clots from forming. Taking your medicine as directed is very important. If a stent was inserted, the medicine reduces the risk that blood clots will form in the stent. Blood clots in the stent can block blood flow and cause a heart attack.
Recovery and Recuperation
Most people recover from angioplasty and return to work about 1 week after being sent home. Your doctor will want to check your progress after you leave the hospital. During the follow-up visit, your doctor will examine you, make changes to your medicines if needed, do any necessary tests, and check your overall recovery. Use this time to ask questions you may have about activities, medicines, or lifestyle changes, or to talk about any other issues that concern you.

Written by Dr. Mark Steiner, Cardiologist in Orlando