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Cardiac & Heart Surgeries


Coronary Angioplasty (PTCA)

Coronary angioplasty is a procedure used to open blocked or narrowed coronary (heart) arteries. The procedure improves blood flow to the heart muscle.

Over time, a fatty substance called plaque can build up in your arteries, causing them to harden and narrow. This condition is called atherosclerosis.

Atherosclerosis can affect any artery in the body. When atherosclerosis affects the coronary arteries, the condition is called coronary heart disease (CHD) or coronary artery disease.

Angioplasty can restore blood flow to the heart if the coronary arteries have become narrowed or blocked because of CHD.

Angioplasty is a common medical procedure. It may be used to:

  • Improve symptoms of CHD, such as angina and shortness of breath. (Angina is chest pain or discomfort.)
  • Reduce damage to the heart muscle caused by a heart attack. A heart attack occurs if blood flow through a coronary artery is completely blocked. The blockage usually is due to a blood clot that forms on the surface of plaque. During angioplasty, a small balloon is expanded inside the coronary artery to relieve the blockage.
  • Reduce the risk of death in some patients.

Who Needs Coronary Angioplasty?

Coronary angioplasty is used to restore blood flow to the heart when the coronary (heart) arteries have become narrowed or blocked because of coronary heart disease (CHD).

Angioplasty is one of a number of treatments for CHD. Other treatments include medicines and coronary artery bypass grafting (CABG). Your doctor will consider many factors when deciding what treatment or combination of treatments to recommend.

Compared with CABG, some advantages of angioplasty are that it:

  • Doesn't require an incision (cut)
  • Doesn't require general anesthesia (that is, you won't be temporarily put to sleep during the procedure)
  • Has a 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 rupture. This can cause a blood clot to form on the plaque's surface and block blood flow. The lack of oxygen-rich blood to the heart can damage the heart muscle.

Quickly opening a blockage lessens the damage during a heart attack by restoring blood flow to the heart muscle. Angioplasty usually is the fastest way to open a blocked artery and is the best approach during a heart attack.

A disadvantage of angioplasty, when compared with CABG, is that the artery more frequently renarrows over time. However, the risk of this happening is lower when stents are used, especially stents coated with medicines (drug-eluting stents).

Stents are small mesh tubes that support the inner artery wall. They reduce the chance of the artery becoming narrowed or blocked again. Some stents are coated with medicines that are slowly and continuously released into the artery. The medicines help prevent the artery from becoming blocked again.

How Is Coronary Angioplasty Done?

Before coronary angioplasty is done, your doctor will need to know the location and extent of the blockages in your coronary (heart) arteries. To find this information, your doctor will use coronary angiography. This test uses dye and special x rays to show the insides of your arteries.

During angiography, a small tube (or tubes) called a catheter is inserted in an artery, usually in the groin (upper thigh). The catheter is threaded to the coronary arteries.

Special dye, which can be seen on an x ray, is injected through the catheter. X-ray pictures are taken as the dye flows through your coronary arteries. This outlines blockages, if any are present, and tells your doctor the location and extent of the blockages.

For the angioplasty procedure, another catheter with a balloon on its tip (a balloon catheter) is inserted in the coronary artery and positioned in the blockage. The balloon is then expanded. This pushes the plaque against the artery wall, relieving the blockage and improving blood flow.

Coronary Balloon Angioplasty

Coronary Balloon Angioplasty


The illustration shows a cross-section of a coronary artery with plaque buildup. The coronary artery is located on the surface of the heart. Figure A shows the deflated balloon catheter inserted into the narrowed coronary artery. In figure B, the balloon is inflated, compressing the plaque and restoring the size of the artery. Figure C shows the widened artery.

A small mesh tube called a stent usually is placed in the artery during angioplasty. The stent is wrapped around the deflated balloon catheter before the catheter is inserted in the artery.

When the balloon is inflated to compress the plaque, the stent expands and attaches to the artery wall. The stent supports the inner artery wall and reduces the chance of the artery becoming narrowed or blocked again.

Some stents are coated with medicines that are slowly and continuously released into the artery. These are called drug-eluting stents. The medicines help prevent the artery from becoming blocked with scar tissue that grows in the artery.

Angioplasty With Stent Placement

Angioplasty With Stent Placement

The illustration shows the placement of a stent in a coronary artery with plaque buildup. Figure A shows the deflated balloon catheter and closed stent inserted into the narrowed coronary artery. The inset image on figure A shows a cross-section of the artery with the inserted balloon catheter and closed stent. In figure B, the balloon is inflated, expanding the stent and compressing the plaque to restore the size of the artery. Figure C shows the stent-widened artery. The inset image on figure C shows a cross-section of the compressed plaque and stent-widened artery.

Cardiologists do coronary angioplasties at hospitals. Cardiologists are doctors who specialize in diagnosing and treating heart diseases and conditions.

If your angioplasty isn't done as an emergency treatment, you'll meet with your cardiologist before the procedure. He or she will go over your medical history (including the medicines you take), do a physical exam, and talk to you about the procedure.

Your doctor also may recommend some routine tests, such as blood tests, an EKG (electrocardiogram), and a chest x ray.

Once the angioplasty is scheduled, your doctor will advise you:

  • When to begin fasting (not eating or drinking) before the procedure. Often you have to stop eating and 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 only 1 to 2 hours, you'll likely need to stay in the hospital overnight or 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.

Coronary angioplasty is done 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 blockages in your coronary arteries.

Preparation

In the cath lab, you'll 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.

To prepare for the procedure, the area where your doctor will insert the catheter will be shaved. The catheter usually is inserted in your groin (upper thigh). The shaved area will be cleaned and then numbed. The numbing medicine may sting as it's going in.

The Procedure

During angioplasty, you'll be awake but sleepy.

Your doctor will use a needle to make a small hole in an artery in your arm or groin. A thin, flexible guide wire will be inserted into the artery through the small hole. The needle is then removed, and a tapered tube called a sheath is placed over the guide wire and into the artery.

Next, your doctor will put a long, thin, flexible tube called a guiding catheter through the sheath and slide it over the guide wire. The catheter is moved to the opening of a coronary artery, and the guide wire is removed.

Next, your doctor will inject a small amount of special dye through the catheter. This will help show the inside of the coronary artery and any blockages on an x-ray picture called an angiogram.

Another guide wire is then put through the catheter into the coronary artery and threaded past the blockage. A thin catheter with a balloon on its tip (a balloon catheter) is threaded over the wire and through the guiding catheter.

The balloon catheter is positioned in the blockage. The balloon is then inflated. This pushes the plaque against the artery wall, relieving the blockage and improving blood flow through the artery. Sometimes the balloon is inflated and deflated more than once to widen the artery. Afterward, the balloon catheter, guiding catheter, and guide wire are removed.

A drill-like device called a rotablator sometimes is used to remove very hard plaque from the artery.

Your doctor may put a stent (small mesh tube) in your artery to help keep it open. If so, the stent will be wrapped around the balloon catheter.

When your doctor inflates the balloon, the stent will expand against the wall of the artery. When the balloon is deflated and pulled out of the artery with the catheter, the stent remains in place in the artery.

After the PCI is done, the sheath, guide wires, and catheters are removed from your artery. Pressure is applied to stop bleeding at the catheter insertion site. Sometimes a special device is used to seal the hole in the artery.

During the PCI, you'll receive strong antiplatelet medicines through your IV line. These medicines help prevent blood clots from forming in the artery or on the stent. Your doctor may start you on antiplatelet medicines before the procedure.

After coronary angioplasty, you'll be moved to a special care unit. You'll stay there for a few hours or overnight. You must lie still for a few hours to allow the blood vessel 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'll be able to walk with help.

The place where the catheters (tubes) were inserted may feel sore or tender for about a week.

Going Home

Most people go home the day after the procedure. When your doctor thinks you're ready to leave the hospital, you'll get instructions to follow at home, such as:

  • 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 shortness of breath; a fever; or signs of infection, pain, or bleeding where the tubes were inserted.
  • 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 you got a stent during angioplasty, 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 leaving the hospital. 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.

Lifestyle Changes

Although angioplasty can reduce the symptoms of coronary heart disease (CHD), it isn't a cure for CHD or the risk factors that led to it. Making healthy lifestyle changes can help treat CHD and maintain the good results from angioplasty.

Talk with your doctor about your risk factors for CHD and the lifestyle changes you'll need to make. For some people, these changes may be the only treatment needed.

Lifestyle changes may include changing your diet, quitting smoking, doing physical activity regularly, losing weight or maintaining a healthy weight, and reducing stress. You also should take all of your medicines exactly as your doctor prescribes.

Cardiac Rehabilitation

Your doctor may recommend cardiac rehabilitation (rehab). Cardiac rehab is a medically supervised program that helps improve the health and well-being of people who have heart problems.

Cardiac rehab includes exercise training, education on heart healthy living, and counseling to reduce stress and help you return to an active life. Your doctor can tell you where to find a cardiac rehab program near your home.

Coronary angioplasty is a common medical procedure. Serious complications don't occur often. However, they can happen no matter how careful your doctor is or how well he or she does the procedure. Serious complications include:

  • Bleeding from the blood vessel where the catheters were inserted.
  • Blood vessel damage from the catheters.
  • An allergic reaction to the dye given during the angioplasty.
  • An arrhythmia (irregular heartbeat).
  • The need for emergency coronary artery bypass grafting during the procedure (2–4 percent of people). This may occur if an artery closes down instead of opening up.
  • Damage to the kidneys caused by the dye used.
  • Heart attack (3–5 percent of people).
  • Stroke (less than 1 percent of people).

Sometimes chest pain can occur during angioplasty because the balloon briefly blocks blood supply to the heart.

As with any procedure involving the heart, complications can sometimes, though rarely, cause death. Less than 2 percent of people die during angioplasty.

The risk of complications is higher in:

  • People aged 75 and older
  • People who have kidney disease or diabetes
  • Women
  • People who have poor pumping function in their hearts
  • People who have extensive heart disease and blockages in their coronary (heart) arteries

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.

Complications From Stents

Restenosis

After angioplasty, the treated coronary artery can become narrowed or blocked again, often within 6 months of angioplasty. This is called restenosis. When a stent (small mesh tube) isn't used during angioplasty, 4 out of 10 people have restenosis.

The growth of scar tissue in and around a stent also can cause restenosis. When a stent is used, 2 out of 10 people have restenosis.

Stent Restenosis

Stent Restenosis

The illustration shows the restenosis of a stent-widened coronary artery. In figure A, the expanded stent compresses plaque, allowing normal blood flow. The inset image on figure A shows a cross-section of the compressed plaque and stent-widened artery. In figure B, over time, scar tissue grows through and around the stent. This causes a partial blockage of the artery and abnormal blood flow. The inset image on figure B shows a cross-section of the tissue growth around the stent.

Stents coated with medicine reduce the growth of scar tissue around the stent and lower the chance of restenosis even more. When these stents are used, about 1 in 10 people has restenosis.

Other treatments, such as radiation, can help prevent tissue growth within a stent. For this procedure, a wire is put through a catheter to where the stent is placed. The wire releases radiation to stop any tissue growth that may block the artery.

Blood Clots

Studies suggest that there's a higher risk of blood clots forming in medicine-coated stents compared to bare metal stents. However, no conclusive evidence shows that these stents increase the chances of having a heart attack or dying, if used as recommended.

When medicine-coated stents are used in people who have advanced CHD, there is a higher risk of blood clots, heart attack, and death. Researchers continue to study medicine-coated stents, including their use in people who have advanced CHD.

Taking medicine as prescribed by your doctor can lower your risk of blood clots. People who have medicine-coated stents usually are advised to take anticlotting medicines, such as clopidogrel and aspirin, for months to years to lower the risk of blood clots.

As with all procedures, it's important to talk with your doctor about your treatment options, including the risks and benefits.



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