Angioplasty and stenting

Based on the nature and extent of the condition, the physician will use the results of the angiogram to determine the most appropriate treatments, which may include:

Potential Coronary angioplasty and stenting: Opening clogged heart arteries

Coronary angioplasty, also referred to as percutaneous coronary intervention (PCI), is a medical procedure used to open clogged heart arteries.

Coronary angioplasty can improve some of the symptoms associated with blocked arteries, such as chest pain and shortness of breath, or can be used during a heart attack to quickly open a blocked artery and minimize heart damage.

Angioplasty (AN-je-o-plast-tee) involves temporarily inserting and expanding a tiny balloon at the site of your blockage to help widen a narrowed artery. Angioplasty is usually combined with implantation of a small metal coil called a stent in the clogged artery to help prop it open and decrease the chance of it narrowing again (restenosis).

Coronary angioplasty has become a common medical procedure with more than 1 million done in the United States every year.

Who is angioplasty for?

When medications or lifestyle changes aren't enough to reduce the effects of artery blockages, or if you have a heart attack, worsening chest pain or other symptoms, your doctor might suggest angioplasty. First you'll have an imaging test called a coronary angiogram to determine if your blockages can be treated with angioplasty.

You may be a good candidate for an angioplasty if:

• Your blockage is small
• Your blockage can be reached by angioplasty
• The artery affected isn't the main vessel supplying blood to the left side of your heart
• You don't have heart failure

If the main artery supplying the left side of your heart is narrowed, if your heart muscle is weak or if you have small, diffusely diseased blood vessels, then coronary artery bypass surgery (CABG) may be a better option. In addition, if you have diabetes and multiple blockages, your doctor may suggest coronary artery bypass surgery. The decision of angioplasty versus bypass surgery will depend on the details of your heart disease and overall medical condition.

How do you prepare for angioplasty?

Before a scheduled angioplasty, your doctor will review your medical history and perform a physical exam. You'll receive instructions on what you can or can't eat or drink before the procedure. Typically, you have to stop eating or drinking by midnight the night before. Your preparation may vary slightly if you're already hospitalized.

Whether the angioplasty is prescheduled or done as an emergency, you'll likely have some routine tests first, including a chest X-ray, electrocardiogram (ECG) and blood tests.

Other tips:

• Follow your doctor's instructions about adjusting your current medications before angioplasty. Your doctor may instruct you to stop taking certain medications before angioplasty, particularly if you take certain diabetes medications or blood thinners.
• Take all of your medications to the hospital with you, including nitroglycerin, if you take it.
• Take approved medications with only small sips of water.
• Tell your doctor or nurse if you're allergic to any medications.
• Arrange for transportation home; angioplasty may require an overnight hospital stay.

Who performs an angioplasty?

Angioplasty is performed by a heart specialist (cardiologist) and a team of specialized cardiovascular nurses and technicians, usually in a cardiac catheterization laboratory. Ideally, an angioplasty will be done only at a medical institution with backup cardiac surgical facilities or access to rapid emergency transport services because of a small risk of complications that could require emergency heart surgery.

Generally, the more practice in doing a procedure, the better the outcome. Research has shown the best angioplasty outcomes are those done by doctors who do at least 75 angioplasties a year and in hospitals that perform at least 400 angioplasties annually.

What happens during an angioplasty?

Coronary angioplasty isn't considered surgery because it's less invasive — your body isn't cut open except for a very small puncture in a blood vessel in the leg, arm or wrist through which a small, thin tube (called a catheter) is threaded and the procedure performed. The entire procedure can take 30 minutes to several hours.

Angioplasty is commonly performed through an artery in your groin (femoral artery). Less commonly, it may be done using an artery in your arm or wrist area.

• Before the procedure, the area is prepared with antiseptic solution and a sterile drape is placed over your body.
• A local anesthetic is injected into your groin to numb the area.
• Small electrode pads are placed on your chest to monitor your heart rate and rhythm during the procedure.

General anesthesia isn't needed, so you're awake during the procedure. You'll receive fluids and medications for relaxation and mild sedation through an intravenous catheter. You'll get blood-thinning medications (anticoagulants) to reduce blood clotting, and then the procedure begins:

• After numbing the incision area, a small cut is made, usually in your leg, to access an artery. Your doctor will then insert a thin guide wire into the artery and thread it through the artery from the incision area up to your blockage.
• Once the guide wire reaches the blockage, a small, thin tube (catheter) is passed over the wire until it reaches the blockage. You might feel pressure in your groin while this is being done, but you shouldn't feel sharp pain. You also won't feel the catheter in your body.
• A small amount of contrast agent, or dye, is injected through the catheter. This helps your doctor look at the blockage on X-ray images called angiograms.
• A small balloon at the end of the catheter is inflated, widening the blocked artery. The balloon stays inflated for up to several minutes at the site of the blockage, stretching out the artery before it's deflated and removed. Your doctor might inflate and deflate the balloon several times before it's removed, stretching the artery a bit more each time to widen it.

Because the balloon temporarily blocks blood flow to part of your heart, it's common to experience chest pain while it's inflated. If you have several blockages, the procedure may be repeated at each site.

Stents provide added support

Once the artery is widened, a device called a stent is usually placed in the artery to act as scaffolding to help prevent it from re-narrowing after the angioplasty. The stent looks like a very tiny coil of wire mesh. Stents can be coated with medication that's slowly released to help prevent arteries from re-clogging. These coated stents are called drug-eluting stents, in contrast to non-coated versions, which are called "bare-metal" stents.

Here's what happens:

• The stent is collapsed, placed around a balloon at the tip of the catheter and guided through the artery to the blockage.
• At the blockage, the balloon is inflated and the spring-like stent expands and locks into place inside the artery.
• The stent remains in the artery permanently to hold it open and improve blood flow to your heart.
• Once the stent is in place, the balloon catheter is removed and more images (angiograms) are taken to see how well blood flows through your newly widened artery.
• Finally, the guide catheter is removed and the procedure completed.

After your stent placement, you may need prolonged treatment with medications to reduce the chance of blood clots forming on the stent material.

The recovery period

You'll probably be able to go home the same day — infrequently you will remain in the hospital — while your heart is monitored and your vital signs are checked frequently. Your doctor will likely prescribe medications aspirin and Plavix to prevent blood clots, relax your arteries and protect against coronary spasms.

When you return home, drink plenty of fluids to help rid your body of the contrast dye. Avoid strenuous exercise and lifting heavy objects for several days afterward. Ask your doctor or nurse about other restrictions in activity.

Call your doctor's office or hospital staff immediately if:

• The catheter insertion site starts bleeding or swelling
• You develop increasing pain or discomfort at the insertion site
• You have signs of infection, such as redness, drainage or fever
• There's a change in temperature or color of the leg or arm that was used for the procedure
• You feel faint or weak
• You develop chest pain or shortness of breath

You should be able to return to work or your normal routine the week after angioplasty.

Results

For most people, coronary angioplasty greatly increases blood flow through the previously blocked artery. Your chest pain should subside, and you may have a better ability to exercise.

Lifestyle modifications will help you maintain your good results, including:

• Stopping smoking
• Lowering your cholesterol levels
• Maintaining a healthy weight
• Controlling other conditions, such as diabetes and high blood pressure
• Getting regular exercise
• Most importantly, to continue taking medications including aspirin, beta blockers and lipex therapy

Successful angioplasty also means you might not have to undergo a more invasive surgical procedure called coronary artery bypass surgery. In a bypass, an artery or a vein is removed from a different part of your body and sewn to the surface of your heart to take over for the blocked coronary artery. This surgery requires a large incision in the chest. Recovery from bypass surgery is usually longer and more uncomfortable.

If you have many blockages or narrowing of the main artery leading to the heart, reduced heart function, or diabetes, then your doctor may recommend bypass surgery instead of angioplasty and stent placement. In addition, for technical reasons some blockages may be better treated with bypass surgery.

Benefits of angioplasty

As with most medical procedures, angioplasty has both benefits and risks.

Among the benefits are:

• It doesn't require a major incision.
• You don't need general anesthesia.
• Major complications are uncommon.
• It can relieve your symptoms, such as chest pain.

Risks of angioplasty

Restenosis - Angioplasty isn't without some risks. A major drawback of coronary angioplasty is the potential for your artery to re-narrow (restenosis) within months of the procedure. With angioplasty alone — without stent placement — restenosis happens in as many as 30 percent to 40 percent of cases. Stents were developed to reduce restenosis. The original bare-metal stents reduce the chance of restenosis to less than 20 percent, and the use of drug-eluting stents has reduced the risk to less than 10 percent.

Blood clots - Recent studies have raised concern about the risk of blood clots forming within stents long term — meaning weeks or months after angioplasty. These clots may cause a heart attack — the exact opposite goal of angioplasty. Some studies have suggested that drug-eluting stents increase this clotting risk, compared with bare-metal stents, but the findings of other studies have not been conclusive. This issue is being studied by the Food and Drug Administration (FDA). Because drug-eluting stents are relatively new, long-term results are not yet available. Regardless of the type of stent placed, it is absolutely necessary to take aspirin, clopidogrel (Plavix) and other medications as prescribed to decrease the chance of clots forming in the stent.

Other risks of angioplasty include:

• Bleeding. You may experience heavy bleeding, requiring a transfusion or other medical procedures.
• Damage. Your artery may be damaged during the procedure, requiring emergency bypass surgery.
• Heart attack. You may have a heart attack during the procedure, though large heart attacks are rare.
• Ongoing disease.
  The procedure doesn't fix the underlying cause of the blocked artery,
  which means other parts of the artery and other arteries can become
  blocked.

Blood thinners

It is very important that you closely follow your doctor's recommendations concerning duration of treatment with anti-platelet agents — aspirin and clopidogrel or similar medications.

Most people who have undergone angioplasty with or without stent placement will need to take aspirin for life. Those who have had stent placement will need clopidogrel for six to 12 months or longer in some cases. If you have any questions or if you need noncardiac surgery, you should talk to your cardiologist before stopping any of these medications.

Most people who have angioplasty and stent placement do well, often for many years. However, if you have recurrent symptoms of chest pain or shortness of breath, or other symptoms similar to before your procedure, you should contact your doctor. If you have chest pain at rest or pain that doesn't respond to nitroglycerin, you should call 111 or emergency medical help.

What is ahead

Ongoing research is helping find new techniques and medications to improve coronary angioplasty. Stent technology continues to advance, and new and better medications used in conjunction with angioplasty could help by shrinking blockages, decreasing the risk of re-blockage, and preventing blood clots and other complications.

Approved by the U.S. Food and Drug Administration in April 2003, such drug-eluting stents have demonstrated an ability to minimize restenosis to less than 10 percent of cases. This success rate has contributed to the rapid acceptance of drug-eluting stents and possibly contributed to a 25 percent drop in the number of bypass surgeries performed. Recently, there has been concern about sudden clotting within drug-eluting stents usually after withdrawal of blood thinners like Plavix.