Coronary Angioplasty Stent Procedure

What is Coronary Angioplasty?

• Coronary arteries are blood vessels supplying blood to the heart muscle.
• Arteries are narrowed due to cholesterol plaques or blood clot.
• Cholesterol plaque accumulation is termed atherosclerosis and causes chest pain.
• Blood clot formation in heart vessels is called coronary thrombosis and this is responsible for heart attack.
• Coronary Angioplasty or Percutaneous Transluminal Coronary Angioplasty (PTCA) is a procedure performed to open up arteries that are either narrowed significantly or completely occluded.
• Coronary angioplasty and stent procedure is also called Percutaneous Coronary Intervention or simply PCI.

What is done during Coronary Angioplasty?

• During this procedure, a tiny balloon catheter is inserted in a narrowed vessel to widen it and thus improve blood supply to the heart.
• Coronary angioplasty is always combined with stent implantation at the site of balloon dilatation.
• Stents help in keeping the artery open as it acts as a scaffold as well as significantly reduces the chances of repeat narrowing.
• Stents are being coated with medicines to reduce the chances of repeat narrowing within a stent.
• These stents are called drug-coated stents and are used in all angioplasty performed.
• This is a major scientific advance that improved the durability of the angioplasty procedure.

Is angioplasty required for everyone with blocked arteries?

Angioplasty is not for everyone. In certain situations, medicines are suggested or even bypass surgery.

Angioplasty-stent benefits certain groups of patients that include:

• During a heart attack, a quick angioplasty reduces damage to the heart and saves a life. Quick angioplasty means within 60 minutes after arrival in the hospital with a heart attack.
• Persisting Chest Pain despite adequate medicines
• Recent onset chest pain (within 2 weeks)
• Chest pain that is worsening

When is bypass surgery preferred over angioplasty?

 When the left main coronary artery is blocked

• Heart muscle is weak
• Diabetes
• Multiple severe blockages in coronary arteries

What is done in Coronary Artery Bypass Surgery (CABG)?

• The blocked artery is bypassed using a vein from the leg or another artery from the same person.

Is angioplasty safe?  What are the risks?

• Angioplasty is a less invasive way to open blocked arteries but still carries certain risks.
• Re-narrowing of artery:
  During angioplasty tiny balloon is inflated to open the blocked artery. The pressure of the balloon inflation causes injury to the vessel as well as the stent, a foreign material, can potentially lead to repeat narrowing at the site of the stent. It happens in less than 5% with drug stent.

• Blood clots formation:
  Rarely after an angioplasty, blood clots can form within stents even after a successful procedure. Clotting of a stent leads to a heart attack. Fortunately, it is an infrequent issue happening in less than 0.5%. Adherence to two antiplatelet drugs – Aspirin and Clopidogrel or similar is important to prevent this complication. These two antiplatelet medicines are preferably continued for 6-12 months after angioplasty.

• Bleeding:
  Bleeding in the leg or arm where the catheter was inserted. The minor bruising or blackish discolouration is common and not dangerous. Ice fomentation will hasten the healing.

Other rare risks:

• Heart attack:
   Heart attack rarely happens during the procedure secondary to fresh clot formation in coronary arteries. Rupture of the coronary artery can happen in less than 0.2% of patients and can be managed by specially designed stents – covered stents.

• Kidney problems:
  Medicine called contrast dye is used during angioplasty procedure that is potentially toxic to the kidneys. This risk is higher in those with previous kidney problem, diabetes, elderly age etc. This complication can be prevented to a large extent by adopting safe kidney practices such as maintaining adequate hydration, using special contrast medicine and limiting the amount of contrast used during the procedure.
• Stroke:
  An extremely rare complication during angioplasty can happen due to the blood clots formed within the catheters. These blood clots travel to the brain and occlude certain brain vessels leading to paralytic stroke. Using blood thinners during the procedure potentially prevents this.

At the hospital what happens:

Before the Angioplasty Procedure:

• A detailed review of medical history, physical examination, blood investigation, an echocardiogram to estimate fitness for angioplasty would be performed.
• An angiogram is usually performed to estimate the number of blocks and whether they can be eminently treated by angioplasty.
• If the doctor finds a blockage, it’s advisable to perform angioplasty and stenting immediately after the angiogram while the heart is still catheterized.
• The doctor will give you instructions to help you prepare.
• It is prudent to stop eating or drinking for eight hours before the angioplasty.
• All your medicines need to be brought to the hospital, as this is an opportunity to reconcile them.
• Angioplasty usually requires a single night stay and you need to organize your transport back for the next day.

During the Angioplasty Procedure

• Cardiologist and his team of technical staff perform angioplasty in a specialized operating room cardiac catheterization laboratory.
• This room has an X-ray machine and other equipment to perform a successful procedure. No need to be anxious about seeing this huge equipment.
• The procedure is performed through the wrist in 98% of cases but for some groin, access is needed.
• The procedure is performed under local anaesthesia and may need a sedative to relax. Usually one remains awake during the procedure.
• Intravenous access is kept in place to give fluids, medications to relax you as well as blood thinners.
• Dedicated apparatus to continuously measure heart rate, blood pressure, and oxygen level is placed on leg or arm.
• Groin and wrist are prepared with an antiseptic solution and a sterile sheet placed over the body.
• Local anaesthesia is administered to numb the area from where the catheter (small plastic tube) is inserted into the body.
• With the help of live X-rays, the catheter is threaded to reach the heart.
• Special medicine called contrast dye is used to visualize the heart vessels. The doctor can identify the blocks, severity, length as well as the number and special characteristics.
• A tiny balloon catheter with or without a stent is inflated at the site of the blockage, widening the artery. After the artery is stretched, the balloon is deflated and the catheter is removed.
• In the presence of multiple blocks, the same procedure may be repeated at every block location.
• The procedure usually takes 60-90 minutes based on the complexity of lesion.
• Pain is unusual in an angioplasty procedure, even if present is for a brief duration.

Stent placement

Angioplasty is accompanied by stent implantation at the same time. The stent is a tiny coil of wire mesh that supports the wall of the coronary artery and prevents collapse as well as re-narrowing after angioplasty

What are the benefits of Coronary Angioplasty?

• Symptom Relief:
  Patients who had narrowed heart blood vessels experience symptoms such as chest pain and shortness of breath. Angioplasty is a very effective therapy to relieve these symptoms.
• Saving Lives:
  Angioplasty is effective in opening a blocked artery during a heart attack, saving lives and preserving heart muscle.

How is a stent implanted into the blood vessel?

• Stents are mounted on a balloon in a collapsed position. This balloon catheter reaches the heart under X-ray guidance up to the location of the block.
• Once the exact location and its relation to block are confirmed, the balloon is inflated. This balloon inflation expands the wire mesh of the stent and locks it to the vessel wall. The stent is released at very high pressure so that this will not move even after release.
• Once the stent is in place, the balloon catheter is deflated and removed.
• This stent remains permanently in the body and over the next few months, a fresh layer of cell lining is formed over the stent.
• More X-ray images (angiograms) are taken to see how well blood flows through the newly widened artery.
• In the case of multiple blocks, additional stents are placed.
• Most stents implanted during an angioplasty are drug-coated. The medication in the stent is slowly released to help prevent future plaque buildup and the re-narrowing of the blood vessel.

After stent placement:

• After stent placement, medications such as aspirin, clopidogrel, ticagrelor or prasugrel, to reduce the chance of blood clots forming on the stent.
• In case of a non-emergency procedure, one needs to remain overnight in the hospital while the heart is monitored and medications are adjusted.
• One generally should be able to return to work or normal routine the week after angioplasty.
• After returning home, it is advisable to drink plenty of fluids to help flush the body of contrast dye.
• Avoid strenuous exercise and lifting heavy objects for at least a day afterwards.

Blood thinners:

• It’s important to closely follow doctor’s recommendations about your treatment with blood-thinning medications — aspirin and clopidogrel or similar medications.
• Most people who have undergone angioplasty with or without stent placement will need to take aspirin indefinitely. Those who have had stent placement will need a blood-thinning medication, such as clopidogrel, for six months to a year. If you have any questions or need any other type of surgery, talk to a cardiologist before stopping any of these medications.
• Coronary angioplasty greatly increases blood flow through the previously narrowed or blocked coronary artery. Chest pain generally should decrease and may be able to exercise better.
• Having angioplasty and stenting doesn’t mean heart disease goes away.
• One needs to continue healthy lifestyle habits and take medications as prescribed by the doctor.
• In case of symptoms similar to those before your procedure, such as chest pain or shortness of breath, contact doctor soon.
• Chest pain at rest or pain that doesn’t respond to Sorbitrate, call for emergency medical help.

What is a successful angioplasty?

The success of angioplasty is defined in the immediate short term as well as long-term.

• Immediate success is performing the procedure without complications in the next 30 days. Current day angioplasty immediate success rates are 90-95%.
• But the long-term success is not to have to undergo coronary artery bypass surgery, a more invasive procedure that requires longer recovery time. This depends on proper procedure technique using modern technology as well as an excellent post-procedure persuasive partnership with the patient.

How can I get a durable Precision Angioplasty procedure?

• Angioplasty is done using X rays that can study the heart vessels in 2-dimension, whereas intravascular ultrasound (IVUS) provides a 3-dimensional picture of heart vessels as well as the nature and length of a block, precise dimensions of the vessel. This allows the Cardiologist to choose the right preparation before stent implantation, choosing the right size of the stent as well as accurately assessing the result after a stent. All these matters a lot and have been shown to improve the longevity of stent result 2-fold.
• Fractional Flow Reserve (FFR/iFR) is another technology that helps in identifying lesions that need a stent. Unnecessary stent leads to increased complications. Over 5 years in FAME 2 trial, stent implantation guided by FFR technology reduced unnecessary stenting by 50% as well as increased the durability of angioplasty. This technology despite being effective is not being used due to reimbursement issues.
• Rotablator technology is a time-tested technology to better stent deployment in complex hard lesions. Adequate preparation of bed before stent implantation is an important prerequisite. A stent that is appropriately sized for the vessel as well as adequately deployed leads to a durable angioplasty result.

After discharge from hospital:

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

• The site where the catheter was inserted starts bleeding or swelling
• Develop pain or discomfort at the site where the catheter was inserted
• Signs of infection, such as redness, swelling, drainage or fever
• There is a change in temperature or colour of the leg or arm at the procedure site
• One can experience symptoms like fainting or weakness
• Develop chest pain or shortness of breath

Lifestyle modifications after discharge

Following an angioplasty-stent procedure to keep your heart healthy you should:

• Quit smoking
• Eat a healthy diet that is low in saturated fat
• Maintain a healthy weight
• Control other conditions, such as diabetes, high blood pressure, and high cholesterol levels
• Get regular exercise
• Take medications as prescribed by a doctor