Coronary angioplasty and stents

Overview

Coronary angioplasty (AN-jee-o-plas-tee), also called percutaneous coronary intervention, is a procedure used to open clogged heart arteries. Angioplasty uses a tiny balloon catheter that is inserted in a blocked blood vessel to help widen it and improve blood flow to your heart.

Angioplasty is often combined with the placement of a small wire mesh tube called a stent. The stent helps prop the artery open, decreasing its chance of narrowing again. Most stents are coated with medication to help keep your artery open (drug-eluting stents). Rarely, bare-metal stents may be used.

Angioplasty can improve symptoms of blocked arteries, such as chest pain and shortness of breath. Angioplasty is also often used during a heart attack to quickly open a blocked artery and reduce the amount of damage to your heart.

Why it's done

Angioplasty is used to treat the buildup of fatty plaques in your heart's blood vessels. This buildup is a type of heart disease known as atherosclerosis.

Angioplasty may be a treatment option for you if:

• You have tried medications or lifestyle changes but these have not improved your heart health.
• You have chest pain (angina) that is worsening.
• You have a heart attack. Angioplasty can quickly open a blocked artery, reducing damage to your heart.

Angioplasty isn't for everyone. Depending on the extent of your heart disease and your overall health, your doctor may determine that coronary artery bypass surgery is a better option than angioplasty for you.

You may need coronary artery bypass surgery if:

• The main artery that brings blood to the left side of your heart is narrow
• Your heart muscle is weak
• You have diabetes and multiple severe blockages in your arteries

In coronary artery bypass surgery, the blocked part of your artery is bypassed using a healthy blood vessel from another part of your body.

Risks

Although angioplasty is a less invasive way to open clogged arteries than bypass surgery is, the procedure still carries some risks.

The most common angioplasty risks include:

• Re-narrowing of your artery. When angioplasty is combined with drug-eluting stent placement, there's a small risk the treated artery may become clogged again (less than 5%). The risk of re-narrowing of the artery is about 10% to 20% when bare-metal stents are used.

• Blood clots. Blood clots can form within stents even after the procedure. These clots can close the artery, causing a heart attack. It's important to take aspirin in combination with clopidogrel (Plavix), prasugrel (Effient) or another medication that helps reduce the risk of blood clots exactly as prescribed to decrease the chance of clots forming in your stent.

  Talk to your doctor about how long you'll need to take these medications. Never discontinue these medications without discussing it with your doctor.

• Bleeding. You may have bleeding in your leg or arm where a catheter was inserted. Usually this simply results in a bruise, but sometimes serious bleeding occurs and may require a blood transfusion or surgical procedures.

Other rare risks of angioplasty include:

• Heart attack. Though rare, you may have a heart attack during the procedure.
• Coronary artery damage. Your coronary artery may be torn or ruptured during the procedure. These complications may require emergency bypass surgery.
• Kidney problems. The dye used during angioplasty and stent placement can cause kidney damage, especially in people who already have kidney problems. If you're at increased risk, your doctor may take steps to try to protect your kidneys, such as limiting the amount of contrast dye and making sure that you're well hydrated during the procedure.
• Stroke. During angioplasty, a stroke can occur if plaques break loose when the catheters are being threaded through the aorta. Blood clots also can form in catheters and travel to the brain if they break loose. A stroke is an extremely rare complication of coronary angioplasty, and blood thinners are used during the procedure to reduce the risk.
• Abnormal heart rhythms. During the procedure, the heart may beat too quickly or too slowly. These heart rhythm problems are usually short-lived, but sometimes medications or a temporary pacemaker is needed.

How you prepare

Before a scheduled angioplasty, your doctor will review your medical history and do a physical exam. You may need to have some routine tests, including a chest X-ray, electrocardiogram and blood tests, before your procedure. Your doctor will also perform an imaging test called a coronary angiogram to see if the arteries to your heart are blocked and if they can be treated with angioplasty.

If your doctor finds a blockage during your coronary angiogram, it's possible he or she may decide to perform angioplasty and stenting immediately after the angiogram while your heart is still catheterized.

Your doctor will give you instructions to help you prepare.

• Your doctor may instruct you to adjust or stop taking certain medications before angioplasty, such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners. Be sure to tell your doctor about all medications you take, including herbal supplements.
• Usually, you'll need to stop eating or drinking six to eight hours before an angiography.
• Take approved medications with only small sips of water on the morning of your procedure.
• Gather all of your medications to take to the hospital with you, including nitroglycerin, if you take it.
• Arrange for transportation home. Angioplasty usually requires an overnight hospital stay, and you won't be able to drive yourself home the next day.

What you can expect

During the procedure

Angioplasty is performed by a heart specialist (cardiologist) and a team of specialized cardiovascular nurses and technicians in a special operating room called a cardiac catheterization laboratory.

Angioplasty is performed through an artery in your groin, arm or wrist area. General anesthesia isn't needed. You'll receive a sedative to help you relax, but you may be awake during the procedure depending on how deeply you are sedated.

• You'll receive fluids, medications to relax you and blood-thinning medications (anticoagulants) through an IV catheter in your hand or arm.
• Your heart rate, pulse, blood pressure and oxygen level will be monitored during the procedure.
• Your doctor will prepare the area in your leg, arm or wrist with an antiseptic solution and will place a sterile sheet over your body.
• Your doctor will use a local anesthetic to numb the area where a very small incision will be made. A small, thin guidewire is then inserted in the blood vessel.
• With the help of live X-rays, your doctor will thread a thin tube (catheter) through your artery.
• Contrast dye is injected through the catheter once it is in place. This allows your doctor to see the inside of your blood vessels and identify the blockage on X-ray images called angiograms.
• A small balloon with or without a stent at the tip of the catheter is inflated at the site of the blockage, widening the blocked artery. After the artery is stretched, the balloon is deflated and the catheter is removed.
• If you have several blockages, the procedure may be repeated at each blockage.

Angioplasty can take up to several hours, depending on the difficulty and number of blockages and whether any complications arise.

You might feel pressure in the area where the catheter is inserted. You may also feel some mild discomfort when the balloon is inflated and your artery is stretched, but typically you shouldn't feel any sharp pain during the procedure.

Stent placement

Most people who have an angioplasty also have a stent placed in their blocked artery during the same procedure. A stent, which looks like a tiny coil of wire mesh, supports the walls of your artery and helps prevent it from re-narrowing after the angioplasty.

Here's what happens during a stent placement:

• The stent, which is collapsed around a balloon at the tip of the catheter, is 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 stays in the artery permanently to hold it open and improve blood flow to your heart. In some cases, more than one stent may be needed to open a blockage.
• Once the stent is in place, the balloon catheter is deflated and removed.
• More X-ray images (angiograms) are taken to see how well blood flows through your newly widened artery.

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 your stent placement, your doctor will prescribe medications, such as aspirin, clopidogrel (Plavix), ticagrelor (Brilinta) or prasugrel (Effient), to reduce the chance of blood clots forming on the stent.

After the procedure

If you had a nonemergency procedure, you'll probably remain at the hospital overnight while your heart is monitored and your medications are adjusted. You generally should be able to return to work or your normal routine the week after angioplasty.

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

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

• The site where your catheter was inserted starts bleeding or swelling
• You develop pain or discomfort at the site where your catheter was inserted
• You have signs of infection, such as redness, swelling, 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

Blood thinners

It's important that you closely follow your doctor's recommendations about your treatment with blood-thinning medications — aspirin and clopidogrel (Plavix), prasugrel (Effient) 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 if you need any other type of surgery, talk to your cardiologist before stopping any of these medications.

Results

Coronary angioplasty greatly increases blood flow through the previously narrowed or blocked coronary artery. Your chest pain generally should decrease, and you may be better able to exercise.

Having angioplasty and stenting doesn't mean your heart disease goes away. You'll need to continue healthy lifestyle habits and take medications as prescribed by your doctor.

If you experience symptoms similar to those you had before your procedure, such as chest pain or shortness of breath, contact your doctor. If you have chest pain at rest or pain that doesn't respond to nitroglycerin, call 911 or emergency medical help.

To keep your heart healthy after angioplasty, you should:

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

Successful angioplasty also means you might not have to undergo coronary artery bypass surgery, a more invasive procedure that requires longer recovery time.