Coronary Angioplasty & Stenting

Introduction

Coronary angioplasty is a procedure that can make a big difference to people who suffer from heart disease such as angina. Coronary angioplasty widens arteries that have been narrowed by a build-up of fatty deposits and allows blood to flow more freely to the heart.

Coronary angioplasty is a surgical procedure that widens arteries which have been narrowed by a build-up of deposits, allowing blood to flow more freely to the heart, relieving the symptoms of unstable angina.

Vascular stenting, which is often carried out at the same time as a coronary angioplasty, places a permanent wire mesh tube into the artery to hold it open.

Both procedures are carried out by keyhole surgery, which means you only need a few small incisions. The operation also takes a relatively short time and doesn't involve a general anaesthetic, so you recover quickly.

About 45,000 coronary angioplasty procedures, or percutaneous transluminal coronary angioplasty (PTCA), are carried out in the UK each year.

Who might need a coronary angioplasty?

Your doctor will often recommend a coronary angioplasty, if you suffer from a condition called angina or have had a heart attack.

Angina is chest pain which usually happens when you exercise, or in more serious cases, when you're resting.

Angina is caused when the arteries in your heart become narrowed by fatty deposits known as atheroma. This narrowing of the arteries reduces the flow of blood - and oxygen - to your heart. This means it doesn't work efficiently and causes pain.

If an artery becomes completely blocked, this stops the flow of blood to your heart completely and can cause a heart attack. If you have angina while resting you should talk urgently to your doctor or cardiologist (a doctor who specialises in diseases of the heart).

To help diagnose your condition and find out whether coronary angioplasty will help, you'll first have a coronary angiogram (cardiac catheterisation). This is an X-ray which shows whether you have narrow areas in your arteries. The procedure involves having a fine tube - a catheter - inserted into an artery (usually in your groin) and pushed slowly up to your heart.

Dye is then fed through the tube, into your blood stream, and flows to your heart. Narrowed areas of artery will show up on the X-ray. If you've already discussed it with your doctor, and they feel it's the right treatment, you may be able to have the angioplasty done at the same time.

Coronary angioplasty isn't suitable for everyone, with some patients not needing any treatment at all and being able to manage their angina with medication. Some patients may need a "heart bypass" operation, properly known as a coronary artery bypass graft (CABG).

You may be recommended for coronary angioplasty if your angina isn't kept under control by your medication, or if the X-ray reveals narrowing in your heart arteries and your doctor thinks angioplasty will help.  You will also be considered for the procedure if you've already had a heart bypass, but your artery has narrowed again.

If you've already had a heart attack, your doctor may suggest you have a coronary angioplasty, as this can reduce your risk of having another.

In some cases, people who have just had a heart attack have a coronary angioplasty as part of their emergency treatment. It is also known as direct angioplasty.

Prepare yourself for the procedure

If you know you are going to have a coronary angioplasty there are steps you can take beforehand to aid recovery and improve your health:

• If you are overweight you should lose some weight, which will help your health generally
• Give up smoking. This is the single best step you can take for your health. You will have less side-effects from the anaesthetic and will heal much faster
• Take a close look at your diet. To eat healthily you need to have five portions of different types of fruit and vegetables a day, plenty of fibre, not very much fat, and no more than 6g of salt a day
• You should also watch your alcohol consumption and drink in moderation
• Try to stay active. Obviously this will depend on the severity of your angina symptoms and on what your doctor advises

The nurse will discuss your medication and advise you to stop taking Warfarin four days prior to the procedure and Metformin 24 hours before the procedure and not to take beta blockers or ace inhibitors on the morning of your procedure.

You will be asked to shave the hair from the right groin a day or so before the test and you must not eat anything six hours prior to the procedure and only drink clear fluids up to hospital admission.

What happens during a coronary angioplasty?

Your coronary angioplasty will probably be carried out in hospital or in a catheterisation room or laboratory by a cardiologist (heart specialist).

• You'll be asked to lie on your back, on an X-ray table, and be given a local anaesthetic and a drug called clopidogrel to stop clots forming in the stent device which the doctor will use to widen your artery
• The doctor may also give you aspirin, if you are not already prescribed it to thin your blood. An anticoagulant, such as heparin, may also be administered
• You may also have an intravenous (IV) line in a vein, in case you need painkillers or a sedative. However, this procedure is not normally painful, and you won't be able to feel the catheter while the angioplasty is under way
• The doctor will then make a small incision in an artery, usually in your groin, through which they'll pass a balloon-tipped catheter
• Using the X-ray to help guide them, your cardiologist will pass the catheter up through your artery, to your heart. When the tip of the catheter reaches the narrowed - or blocked - section of artery, the balloon will be gently inflated
• The inflating balloon presses against the deposits lining your artery, squashing them against the artery walls. This may be done a number of times, and widens the artery to allow blood to flow through it more freely
• You may feel some pain in your chest when the balloon is inflated, because it can temporarily block the blood flow. However the pain will go once the balloon is deflated
• Your cardiologist will check that the procedure has been successful by injecting dye into the catheter, and checking on the X-ray video that it is flowing through your artery as it should

How long does a coronary angioplasty take?

It usually takes about 30 minutes to carry out a coronary angioplasty.

If you have more than one section of narrowed artery to be treated, it will, of course, take longer. In nine out of 10 cases, coronary angioplasty successfully widens narrowed arteries and restores blood flow.

Coronary stents

In many cases, the procedure will include the use of a stent, which is a tube made of stainless steel mesh.

The stent expands to fit your artery as the balloon is inflated. Once your cardiologist is happy with the procedure, the balloon is deflated, and the catheter is withdrawn, leaving the stent behind to keep the artery open.

If your cardiologist knows in advance that you are going to have a bare stent, you'll be prescribed antiplatelet drugs (clopidogrel) to prevent blood clots from forming around it and an anticoagulant drug (aspirin).

Your doctor will advise you on any medication you need to take after the procedure. You will need to take this for between two weeks and six months, depending on the type and number of stents that you have.

The pros and cons of stents

Stents can reduce the risk of your artery furring up again, while reducing the need to have the procedure done again.  They can be particularly beneficial if your artery was completely blocked.

One disadvantage of using a stent in a coronary angioplasty is that it can put you at greater risk of blood clots - and extra tissue - forming around it.  In the past, this meant that in some cases the arteries became narrowed again (restenosis), and the procedure had to be repeated.

Drug-eluting stents are now used to avoid clots reforming. These stents are coated with a drug which reduces the risk of extra tissue growth, and helps the artery remain clear for longer.

Drug-eluting stents aren't used in all hospitals and aren't suitable for all patients. Talk to your doctor to find out whether this type of stent would be suitable for you, which is available and whether they think it is the best choice. You will still need to take anticoagulant drugs for a period of time after the operation, even if you have a drug-eluting stent fitted.

After the procedure

In most cases you will only need to spend one night in hospital after the procedure, and may even be able to go home on the same day.

However, you shouldn't drive for up to a week, so try to arrange for someone to pick you up and take you home and take care of you for the duration.

Avoid lifting anything heavy until the wound in your groin has healed. You should be able to return to work after a week, and you can have sex when you feel up to it.

However if your angioplasty was carried out following a heart attack, you will need to keep to the rehabilitation programme set out for you at the hospital.

Risks associated with coronary angioplasty

Coronary angioplasty is generally a very safe procedure.

There are some risks involved, however:

• You could develop an infection at the site of the original incision, which can make it sore
• You shouldn't experience chest pain following a coronary angioplasty. If you do, tell a member of the medical team caring for you, immediately. They'll check to find the cause of the pain
• In a small number of cases, the procedure blocks the artery being treated. If your cardiologist thinks this poses a threat to your heart they may arrange for you to have a coronary artery bypass graft (CABG) immediately
• If your angioplasty doesn't successfully clear your narrowed artery, your cardiologist may recommend that you have heart surgery at a later date
• There is also a slight risk of heart attack, stroke and damage to the artery, which is greater for people who already have severe heart disease

Questions to ask your surgeon

Clickthrough information and support link:

British Heart Foundation