Coronary Angioplasty

CORONARY ANGIOPLASTY

The term “angioplasty” means temporarily using a balloon which is inserted to stretch open a narrowed or blocked artery. However, most modern angioplasty procedures also combine this with inserting a short wire-mesh tube, called a stent, to help keep the artery open during the procedure. The stent is left in place permanently to allow blood to flow more freely. Most stents used currently are coated with medication to help keep the artery open (drug-eluting stents) while others are not (bare metal stents).

Why do we do coronary angioplasty?

Angioplasty is used to treat a type of heart disease known as atherosclerosis. Like all organs in the body, the heart needs a constant supply of blood. This is supplied by the coronary arteries. In some people, these arteries can become narrowed and hardened with slow buildup of fatty plaques in your heart’s blood vessels known as atherosclerosis.

If the flow of blood to the heart becomes restricted, it can lead to chest pain known as angina, which is usually triggered by physical activity or stress.

While angina can often be treated with medication, a coronary angioplasty may be required to restore the blood supply to the heart in severe cases where medication and lifestyle changes are not sufficient to imporve symptoms or if symptoms worsen inspite of the above. Coronary angioplasty is also often used as an emergency treatment for a heart attack.

Angioplasty isn’t for everyone. If the main artery that brings blood to the left side of your heart is narrow, if your heart muscle is weak or if you have multiple diseased blood vessels and/or have diabetes then coronary artery bypass surgery may be a better option than angioplasty. In coronary artery bypass surgery, the blocked part of your artery is bypassed using a blood vessel from another part of your body.

The decision of angioplasty versus bypass surgery will depend on the extent of your heart disease and overall medical condition.

What are the benefits of a coronary angioplasty?

In most cases, the blood flow through the coronary arteries improves after an angioplasty. Many people find their symptoms get significantly better and they’re able to do more than they could before the procedure.

If you’ve had a heart attack, an angioplasty can improve outcomes ie. can increase your chances of surviving. There is less long term damage to the heart muscle with less chance of developing breathlessness and heart failure. There is less chance of developing heart rhythms(heart beats) that can be life threatening The procedure can also reduce your chances of having another heart attack in the future.

How do you prepare for coronary angioplasty?

You’ll receive instructions about eating or drinking before angioplasty. Usually, you’ll need to stop eating or drinking four to six before the procedure is scheduled.

Your preparation may be different if you’re already staying at the hospital before your procedure.

During your pre-operative assessment, you may also have an ECG, CXR, blood tests and a general health check to ensure you’re suitable for surgery.

The night before your procedure, you should follow your doctor’s instructions about adjusting your current medications before angioplasty.

Take approved medications with only small sips of water.(may vary so best to check with your doctor)

You’ll usually be able to take most medications as normal up to the day of the procedure, with the exception of blood-thinning medication such as warfarin, dabigatran, rivaroxaban, edoxaban, apixaban. You may also need to alter the timing of any diabetic medication you take.

Arrange for transportation home. Angioplasty usually requires an overnight hospital stay, and you won’t be able to drive yourself home the next day.

The “coronary angioplasty” procedure

Before having a coronary angioplasty you’ll need an assessment by the doctor to make sure the operation is possible. This also gives you an opportunity to discuss any concerns with your cardiologist (heart
specialist).The doctor will first review your medical history and following a physical exam will first do a coronary angiogram.

The coronary angiogram determines if the arteries are narrowed or blocked. 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.

Angioplasty is performed by a heart specialist ( interventional cardiologist) and a team of specialized cardiovascular nurses and technicians in a special operating room called a cardiac catheterization laboratory. A coronary angioplasty usually takes place in a room called a catheterisation laboratory, rather than in an operating theatre. This is a room fitted with X-ray equipment to allow the doctor to monitor the procedure on a screen and is often called a cath lab.

A coronary angioplasty usually takes between 30 minutes and two hours, although it can take longer.

Angioplasty is commonly performed through an artery in the arm or wrist and sometimes through your groin (femoral artery). Before the procedure, the area is prepared with an antiseptic solution and a sterile sheet is placed over your body. Small electrode pads are placed on your chest to monitor your heart during the procedure. You’ll receive fluids, medications to relax you and blood-thinning medications (anticoagulants) through an IV catheter.

You’ll be asked to lie on your back on an X-ray table. You’ll be linked up to a heart monitor and given a local anaesthetic to numb your skin. Both the the coronary angiogram and coronary angioplasty are performed under local anaesthetic which means you’ll be awake while the procedure is carried out.

The cardiologist then makes a small incision in the skin of your groin, wrist or arm, over an artery where your pulse can be felt.  A small tube called a sheath is inserted into the artery to keep it open during the procedure.

A long, flexible plastic tube called a catheter (about the width of the lead in a pencil) is inserted through the sheath and guided along the artery up to the opening of the right or left coronary artery ie the blood vessels of the heart.

You won’t feel the catheter in your body. You might feel pressure in the area where the catheter is inserted, but you shouldn’t feel sharp pain. Tell your doctor if you do.

A special fluid that shows up on X-rays, known as contrast medium, is injected through the catheter. As the dye fills your arteries, they become visible on X-ray and video, so your doctor can see where your arteries are blocked.The resulting pictures are called angiograms

If the doctor decides to proceed to angioplasty with your consent a thin wire is guided through the catheter down the length of the affected coronary artery, delivering a small balloon to the affected section of artery. This is then inflated to widen the artery, squashing fatty deposits against the artery wall so blood can flow through it more freely when the deflated balloon is removed. This may be done several times.

While the balloon is inflated, the artery will be completely blocked and you may have some chest pain. However, this is normal and is nothing to worry about. The pain should go away when the balloon is deflated. Ask your cardiologist for pain medication if you find it uncomfortable.

If a stent is being used, this will be around the balloon before it’s inserted. The stent will expand when the balloon is inflated and the springlike stent expands and locks into place and remains even when the balloon is deflated and removed.

You shouldn’t feel anything else as the catheter moves through the artery, but you may feel an occasional missed or extra heartbeat. This is nothing to worry about and is completely normal.

When the operation is finished, the cardiologist will check that your artery is wide enough to allow blood to flow through more easily. This is done by monitoring a small amount of contrast dye as it flows through the artery.

The balloon, wire, catheter and sheath are then removed and any bleeding is stopped with a dissolvable plug or firm pressure. In some cases, the sheath is left in place for a few hours or overnight before

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.

A coronary angioplasty usually takes between 30 minutes and two hours.

Stents are not affected by security systems at airports or MRI scans.

Post procedure in hospital:

When the tube is removed from the leg or arm, a nurse or doctor will apply pressure or use special devices for 15 minutes or so to stop bleeding.

If the tube was inserted through the leg it is likely you will have to lie quietly on your back for several hours and will have regular checks to ensure there is no bleeding.

If you’re being treated for angina, you’ll normally be able to go home later the same day or the day after you have the procedure.

If you’ve been admitted to hospital following a heart attack, and underwent angioplasty and stenting, you may need to stay in hospital for longer.

Discharge from hospital:

You will need to arrange for someone to take you home.

You will be given advice on medications to take, diet and lifestyle and wound care and hygiene during recovery.

You will be given a date for a follow-up appointment to check on your progress.

Where catheter was inserted:

You may have a bruise under the skin where the catheter was inserted. This isn’t serious, but it may be sore for a few days.

You will have to seek help if there is bleeding, swelling, pain or discomfort at the site of catheter insertion.

If the arm or leg where the catheter was inserted changes colour or becomes swollen or cold you should seek help.

You may also need to seek help is you develop any signs of infection such as redness, swelling or fever or discharge from the site. Occasionally, the wound can become infected. Keep an eye on it to check it’s healing properly.

General:

Your chest may also feel tender after the procedure, but this is normal and usually passes in a few days. If necessary, you can take paracetamol to relieve any pain.

If you develop any chest pain or breathlessness or any symptoms similar to what you had pre-procedure you should again seek help.

You’ll need to avoid heavy lifting, strenuous activities and driving for at least a week.

ACTIVITIES:

WORK:

You generally should be able to return to work the week after angioplasty but it also depends on the work you do.

If you’ve had an emergency angioplasty or a heart attack you may need to take a few weeks off.

Driving

You shouldn’t drive a car for a week after having a coronary angioplasty.

If you drive a heavy vehicle for a living, such as a lorry or a bus, inform the employer that you’ve had a coronary angioplasty.

You should be able to drive again as long as you meet the requirements of an exercise/function test and you don’t have another disqualifying health condition.

Medication:

It is important you follow doctors recommendations regarding blood thinners – usually this is a combination of aspirin and clopidogrel (or prasugrel or ticagrelor)

Most people need to take blood-thinning medications for up to one year after having an angioplasty though with newer stent this can be stopped much earlier.

Your doctor may also stop this combination early if you develop any bleeding problems but the combination should NEVER be stopped unless discussed with the implant physician.

It’s very important you follow your medication schedule. If you stop your medication early, the stent could be blocked and may cause a heart attack

While clopidogrel, prasugrel or ticagrelor are usually withdrawn after about a year, but most people need to continue taking low-dose aspirin for the rest of their life.

Cardiac rehabilitation (CR)

CR will be offered if you’ve had a heart procedure. This programme aims to help you recover from the procedure and get back to everyday life as quickly as possible.

A member of the cardiac rehabilitation team will visit you in hospital and provide detailed information about the nature of disease and natural history, treatment done, recovery and what medication to take.

They will also provide advice on steps to reduce your risk of having further problems in the future such as losing weight, stopping smoking, eating healthy(low fats, carbohydrates and low salt) and being active and exercising regularly.

Smoking and being overweight are two of the main causes of heart disease and they make treatment less likely to work.

Your cardiac rehabilitation programme will begin when you’re in hospital and will continue as outpatient beginning within 10 days and lasting up to 3 months.

Once you’ve completed your rehabilitation programme, it’s important you continue to lead a healthy lifestyle to reduce the risk of further heart-related problems.

Its important to remember that 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.

Is coronary angioplasty safe?

A coronary angioplasty is one of the most common types of treatment for the heart.

Presently, about 3.0 million angioplasty procedures are performed each year worldwide with the US alone accounting for almost a million of these procedures. Major complications from cardiac catheterization occur in less than 2% of the population, with mortality of less than 0.08%

As the procedure doesn’t involve making major incisions in the body, it’s usually carried out safely in most people. Doctors refer to this as a minimally invasive form of treatment.

As with all types of surgery, coronary angioplasty carries a risk of complications. However, the risk of serious complications from a coronary angioplasty is generally small and depends on factors such as age, general health and past medical history of heart attacks or family history etc.

Serious problems that can occur as a result of the procedure include excessive bleeding, a heart attack and a stroke

Complications that can occur during or after an angioplasty include:

  • damage to the artery where the sheath was inserted – estimated to occur in 0.2 to 1%
  • allergic reaction to the contrast agent used during the procedure – estimated to occur in less than one in every 100 cases
  • damage to an artery in the heart – risk is about 0.3 to 0.6%
  • abnormal hearth rhythms risk is about 0.1%
  • excessive bleeding requiring a blood transfusion – estimated to occur in less than one in every 100 cases
  • heart attack, – risk is about 0.05% in recent times.
  • stroke  can occur rarely i.e – 0.07% risk during coronary angiograms to 0.44% in those undergoing PCI in recent trials.
  • or death – estimated to be around 1.27% ( varying from 0.65% if elective procedure to 4.81% in those with heart attack)
    the risk however increases
    – with age
    – if procedure done as emergency
    – in presence of kidney disease
    – the location and extent of blockages
    – previous heart disease especially heart muscle damageYour cardiology team can give you more information about your individual circumstances and level of risk.Stents
    A stent is a short, wire-mesh tube that acts like a scaffold to help keep your artery open. There are two main types of stent:
  • bare metal (uncoated) stent
  • drug-eluting stent – which is coated with medication that reduces the risk of the artery becoming narrowed and blocked again previously Bare metal stents were used extensively. But, the body would see the stent as a foreign body and the immune system would attack it, causing excessive tissue growth inside the stent with narrowing and blockage occurring in upto 30% of the heart blood vessels.
    Drug-eluting stents or stents that are coated with medication tends to reduce this excessive healing response which results in narrowing and blockage occuring again. However, this also delays the healing of the coronary artery and it takes longer for the artery to develop a protective coating inside the stent. Therefore as the process can take upto 6 months or longer it is important to take blood thinners to keep the blood flowing and not stick to the exposed stent struts and cause blood clots and blockage of blood flow. This is what causes a heart attack. You may have to take these medications up to one year after the procedure though with newer stents this time is becoming shorter. The two most common types of medication are:
  • “-limus” medications (such as sirolimus, everolimus and zotarolimus) – which have previously been used to prevent rejection in organ transplants
  • paclitaxel – which inhibits cell growth and is commonly used in chemotherapyThe use of drug-eluting stents has reduced the rate of arteries re-narrowing from less than one in 10 and they are now used in the majority of stent procedures.Before your procedure, discuss the benefits and risks of each type of stent with your cardiologist.

Activities

Your hospital team can usually advise you about how long it will take to recover and if there are any activities you need to avoid in the meantime.

In most cases, you’ll be advised to avoid heavy lifting and strenuous activities for about a week, or until the wound has healed.

GOV.UK has more information on coronary angioplasty and driving.

Work

If you had a planned (non-emergency) coronary angioplasty, usually you should be able to return to work after a week though you may want to check with your doctor as it may also depend on your occupation.

If you had a heart attack and underwent emergency angioplasty, you may want to discuss with your doctor as it maybe much longer and also depends on your work.

Sex

You may be able to have a more active sex life as soon as you feel ready after a coronary angioplasty and if you have no symptoms on moderate exertion.(ie able to climb a couple of flights of stairs)

If you have any concerns, speak to your physician.

Further course:

You may need to have another angioplasty if your artery becomes blocked again and your angina symptoms return. Alternatively, you may need a Coronary Artery Bypass Grafting(CABG)

What is the alternative?

The most widely used surgical alternative to a coronary angioplasty is a coronary artery bypass graft (CABG).

A CABG or Coronary Artery Bypass Grafting could be considered if
– many of the coronary arteries have become blocked and narrowed
– or the structure of your arteries is abnormal
– the main artery on the left has severe disease with or without blockages or narrowing elsewhere
– if heart muscle function is very poor
– diabetes with mutiple vessel blockages

This is a type of invasive surgery where sections of healthy blood vessel are taken from other parts of the body(vein or artery from your legs, arms or chest are used to create a new channel) and attached to the coronary arteries. Blood bypasses the blocked sections and takes blood beyond the diseased part to the heart muscles beyond.

Complications of CABG are uncommon, but are potentially serious. They
include:

  • a heart attack – estimated to occur in one in every 15-50 cases
  • a stroke– estimated to occur in one in every 50 cases

However, as CABG is invasive surgery it may not be suitable for people who are particularly frail and in poor health.

A CABG may also be used if the anatomy of the blood vessels near your heart is abnormal because a coronary angioplasty may not be possible in these cases.

Which procedure is best for you?

You may not always be able to choose between having a coronary angioplasty or a CABG, but if you are it’s important to be aware of the advantages and disadvantages of each technique.

As a coronary angioplasty is minimally invasive, you’ll recover from the effects of the operation quicker than you will from a CABG. Coronary angioplasty usually has a smaller risk of complications, but there’s a chance you’ll need further treatment because the affected artery may narrow again.

However, the number of people who need further surgery has fallen because of the use of drug-eluting stents.

CABG has a longer recovery time than coronary angioplasty and a higher risk of complications. However, only one person in 10 who has a CABG requires further treatment. Also, some evidence suggests that CABG is more effective treatment option for people in certain types of blockages or when the heart muscle is severely affected or if there are multiple blockages along with diabetes.

You should discuss the benefits and risks of both types of treatment with your cardiologist and cardiac surgeon before making a decision.