Coronary Angioplasty
Balloon and Stent Angioplasty Procedures

percutaneous coronary intervention


Coronary Angioplasty


What Is Coronary Angioplasty?
Who Needs It?
How Is It Performed?
What Is Stenting?
What Happens After The Procedure?
Are There Any Risks?
How Much Does It Cost?

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Heart Disease in Women

What Is Coronary Angioplasty?

Coronary angioplasty, also known as percutaneous coronary intervention (PCI), is a medical procedure used to open narrowed or blocked arteries of the heart. It results in better blood flow to the heart muscle and improves symptoms of coronary heart disease (CHD) such as angina pain and shortness of breath. A person who arrives in emergency with severe angina or a heart attack probably has one or more coronary arteries that is blocked and the first priority is for surgeons to release the blockage and restore blood flow. Angioplasty will be used in this instance. Once the blockage has been treated, the patient may be recommended coronary heart bypass surgery as a long-term solution to CHD. In non-emergency situations, as medications and lifestyle changes are not always enough to prevent CHD, angioplasty may also be carried out to relieve symptoms of angina or to try and prevent heart attacks occurring. More than 1.2 million angioplasties are carried out every year in the United States (61,000 in the UK). Due to the risk factors of heart disease, angioplasty is most commonly performed on patients over the age of 65. It can also be used to unblock brain and neck arteries to prevent stroke in women and men.

Who Needs It?

Coronary angioplasty is beneficial for people undergoing a heart attack (see heart attack treatment). Numerous studies show that early intervention with angioplasty and stenting (see below for explanation) during a heart attack can save lives. If a patient arrives in hospital due to a heart attack and the hospital has an interventional cardiologist on duty, then angioplasty is the treatment of choice. If the facilities are not available, then thrombolytic therapy is used instead.

Angioplasty is also performed in non emergency situations on people with stable CHD or angina where medication alone cannot control the symptoms. A stable patient is someone who can predict when their symptoms occur. For example, if a woman knows that after walking for 10 minutes at a normal pace she will develop chest pain or an angina attack, her condition is considered stable. However if symptoms start to occur when she is at rest or if pain becomes increasingly worse and appears more frequently, her condition is considered unstable. If her condition is stable, the woman may be recommended angioplasty with stents to help relieve symptoms. A coronary angiography may be performed first to investigate the blockages, although sometimes doctors combine an angiography with angioplasty. It is worth mentioning that studies show that patients with stable CHD who undergo angioplasty do not live longer than those who are only treated with medications. If a patient has unstable CHD it is likely that they have severe blockages in their arteries, and they may rather benefit from coronary bypass surgery. This involves bypassing the disease artery by inserting a new blood vessel or vein graft.

Useful: Know The Causes of Coronary Heart Disease.

How Is It Performed?

Coronary angioplasty is usually performed in a cath lab (catheterization laboratory), which is a specially equipped room in a hospital. The patient will be injected with sedatives and pain medications before the procedure to help them relax. This is known as conscious sedation which means that the patient is awake but their senses are dulled. Electrodes are placed on the patient's chest and are then attached to an electrocardiogram to monitor their heart rate throughout. Next an area of the leg (or sometimes the arm) is cleaned and anesthetized, ready for the insertion of a catheter (cath) which is a long plastic tube (see heart cath). Once the patient is comfortable, a small cut is made and the cath is inserted. The doctor will guide it to through the blood vessels, watching his progress on a nearby monitor. Once the cath is at the entrance of the main coronary artery a contrast dye is injected. This allows the doctor to identify the blocked vessels. Images are taken by an external X-ray machine which hovers over the patient. After studying any blockages he then inserts a device with a tiny deflated balloon into the affected artery. Once in place the balloon is inflated. It expands and squeezes the accumulation of cholesterol and plaque (atherosclerosis) away from the center and back into the wall of the artery. The balloon is kept in place for 2 minutes before being deflated and removed. If necessary the doctor can inflate the balloon several times to reshape the artery. This technique is known as balloon angioplasty but it has now been largely replaced by stenting.

What Is Stenting?

Stenting is a more permanent solution to blocked arteries than balloon angioplasty alone. With this technique, once the cath is in place a small tube made of wire mesh is inserted into the blocked artery to open it. The procedure is performed by a specialist called an interventional cardiologist who uses a balloon to expand the stent at the correct point of the artery. The stent then locks into place once it is opened and any plaque or cholesterol is squeezed behind it. There are two main types of stents: bare-metal and drug-eluting. Bare metal is just that, a stent made of nothing but metal. A drug-eluting stent is covered with a chemical that releases a drug from the metal to stop any scarring over the stent. This is to prevent the necessity of replacing it in the future. Since drug-eluting stents were approved by the FDA in 2003 their popularity has grown rapidly. By the end of 2008, 68 percent of all PCI procedures used drug-eluting stents.

What Happens After The Procedure?

An angioplasty takes anywhere between 45 minutes and 2 hours to perform. Once the cath tube is removed, nurses will stop the bleeding at the point of incision by applying pressure for 15 minutes (or they may use a specially designed pressure device). You will be returned to a hospital room and told to rest for up to 8 hours. A nurse will monitor your heart and blood pressure rate on a regular basis and check the site on incision for signs of bleeding or infection. Most people remain in hospital for 1 to 2 days. On release from hospital, you will need someone to drive you home. You will be told not to stand or walk for long periods for another 48 hours. You should probably avoid any vigorous exercise for about 4 weeks. You may be prescribed the following heart medications:

1. Calcium channel blockers to prevent coronary artery spasm.
2. Nitroglycerin tablets which are a vasodilator that relax and expand the coronary arteries.
3. Aspirin and other antiplatelets may be prescribed to prevent blood clots forming. If a stent was inserted you will need to take blood thinners permanently. An antiplatelet medication like clopidogrel will be necessary for one month after a bare-metal stent and one or more years after a drug-eluting stent. See also: Coronary heart disease treatment.

As stents are made of metal, you should not have an MRI (magnetic resonance imaging) for at least 4 weeks. However you can travel through airport security without causing the alarms to go off.

Are There Any Risks?

Overall angioplasty has been proven to save heart attack victims lives and it relieves discomfort in those with angina. It is generally well tolerated by patients and complications are not very common. If complications do occur, they are not usually severe. The most common complaint is bleeding or discomfort at the site where the cath was inserted. This can be controlled by pressure to the site and taking pain relief medications. Occasionally the technique can cause tears in the blood vessels but these normally heal by themselves. If the tear is severe however, immediate surgery is necessary - this may involve inserting another stent or in severe cases bypass surgery. Some patients can experience chest pain caused by minor tears, or caused by pieces of cholesterol plaque flowing away from the main artery down to smaller vessels where they then cause blockages or spasms. The pain is not normally severe. Other more worrying dangers however include:

This is a constriction or re-narrowing of the artery which may occur within 6 months of the operation. If the artery narrows enough, symptoms of angina can return and a repeat procedure will be necessary. The use of stents make restenosis less likely to occur but it is still a possibility (in-stent restenosis). In such cases healthy tissue grows over the stent and scar tissue can develop under the surface so that space and blood flow is restricted - although those with drug-eluting stents are less likely to have this problem. Patients with diabetes, high blood pressure and high cholesterol are more prone to restenosis. It is important therefore that these conditions are treated after the original surgery. It is also important for the patient to follow coronary heart disease prevention advice such as starting an exercise program, following a healthy low-fat diet and quitting smoking. A cardiac rehabilitation program will show you how to introduce these changes into your life. Fortunately restenosis is not very common and doctors monitor it with follow up treadmill tests and echocardiograms. Other heart monitoring procedures include a Holter Monitor and Event Monitor. See also heart disease testing for an overview of all tests.

Stent Thrombosis
In rare cases a blood clot (thrombosis) can form in the stent which completely blocks the artery. A clot can form immediately after surgery, or it may appear later, although generally if it is to occur it will do so in the first month. Stent thrombosis is a medical emergency because it causes a heart attack. The risk of this happening is reduced by taking aspirin therapy indefinitely or by taking clopidogrel for at least one year.

Special Risks For Women
Women are more like to die after stenting angioplasty than men. This may be because women tend to be older on average when they undergo the procedure. Also, angioplasty tends to be riskier the smaller the blood vessel involved - and women tend to have smaller vessels. Additionally they are more prone to bleeding from both the surgery and the blood thinning medications prescribed after. The good news is however, if they survive angioplasty their long-term outlook is just as good as men. Read about coronary heart disease in women.

How Much Does It Cost?

According to a study by the Stanford University School of Medicine, the average cost of angioplasty with stents is about $21,000. The average UK cost is £8,500.

Registering Your Stent

The hospital that carried out your angioplasty may ask you to take part in a registration process to create online medical records for your stent. If they ask you to participate, you should do so. It means in the case of an emergency your records can be accessed by healthcare providers so that they can learn quickly about what type of stent you have and where it was placed. It also means that the stent manufacturers can contact you if there are any updates on the product, such as a product recall (although this is rare). You will probably also be given a registration card to carry in your purse, or an ID bracelet with relevant information in case of an emergency.

Heart Disease in Pregnancy
UK Heart Disease Statistics
American Heart Disease Statistics
Heart Attacks in Women

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