Percutaneous Transluminal

Coronary Angioplasty / Stent

What is balloon angioplasty?
Balloon angioplasty of the coronary artery, or
percutaneous transluminal coronary angioplasty (PTCA),
was introduced in the late 1970's. PTCA is a non-surgical
procedure that relieves narrowing and obstruction of the
arteries to the muscle of the heart (coronary arteries). This
allows more blood and oxygen to be delivered to the heart
muscle. PTCA, is now referred to as percutaneous
coronary intervention, or PCI, as this term includes the use
of balloons, stents, and atherectomy devices. PCI is
accomplished with a small balloon catheter inserted into an
artery in the groin or arm, and advanced to the narrowing
in the coronary artery. The balloon is then inflated to
enlarge the narrowing in the artery. When successful, PCI
can relieve chest pain of angina, improve the prognosis of
patients with unstable angina, and minimize or stop a
heart attack without having the patient undergo open heart
coronary artery bypass graft (CABG) surgery.
In addition to the use of simple balloon angioplasty, the availability of stainless
steel stents, in a wire-mesh design, have expanded the spectrum of patients
suitable for PCI, as well as enhanced the safety and long-term results of the
procedure. Since the early 1990's, more and more patients are treated with stents,
which are delivered with a PCI balloon, but remain in the artery as a "scaffold".
This procedure has markedly reduced the numbers of patients needing emergency
CABG to below 1%, and particularly with the use of the new "medicated" stents
(stents coated with medications that help prevent plaque formation), has reduced
the rate of recurrence of the blockage in the coronary artery ("restenosis") to well
below 10%. At present, the only patients treated with just balloon angioplasty are
those with vessels less than 2mm (the smallest diameter stent), certain types of
lesions involving branches of coronary arteries, those with scar tissue in old stents,
or those who cannot take the blood thinner medication known as clopidogrel
bisulfate (Plavix). Various "atherectomy" (plaque removal) devices were initially
developed as adjuncts to PCI. These include the use of theexcimer laser for
photoablation of plaque, rotational atherectomy (use of a high-speed diamond-
encrusted drill) for mechanical ablation of plaque, and directional atherectomy for
cutting and removal of plaque. Such devices were initially thought to decrease the
incidence of restenosis, but in clinical trials were shown to be of little benefit, and
now are only used in selective cases as an adjunct to standard PCI (precutaneous
artery intervention).
 How does coronary
artery disease develop?
Arteries that supply blood and oxygen to the heart muscles are called
coronary arteries. Coronary artery disease (CAD) occurs when
cholesterol plaque (a hard, thick substance comprised of varying
amounts of cholesterol, calcium, muscle cells, and connective tissue,
which accumulates locally in the artery walls) builds up in the walls of
these arteries, a process called arteriosclerosis. Over time,
arteriosclerosis causes significant narrowing of one or more coronary
arteries. When coronary arteries narrow more than 50 to 70%, the
blood supply beyond the plaque becomes inadequate to meet the
increased oxygen demand during exercise. Lack of oxygen (ischemia)
in the heart muscle causes chest pain (angina) in most patients.
However, some 25% of patients experience no chest pain at all despite
documented ischemia, or may only develop episodic shortness of
breath instead of chest pain. These patients have "silent angina" and
have the same risk of heart attack as those with angina. When arteries
are narrowed in excess of 90-99%, patients often have angina at rest
(unstable angina). When a blood clot (thrombus) forms on the plaque,
the artery may become completely blocked, causing death of a part of
the heart muscles (heart attack, ormyocardial infarction).
The arteriosclerotic process can be accelerated by
smoking, high blood pressure,elevated cholesterol levels,
and diabetes. Patients are also at higher risk for
arteriosclerosis if they are older (greater than 45 years for
men and 55 years for women) or if they have a positive
family history of coronary heart disease.
How is coronary artery
disease diagnosed?
 The resting electrocardiogram (EKG) is a recording of the electrical
activity of the heart, and can show changes indicative of ischemia or
heart attack. Often, the EKG in patients with coronary artery disease is
normal at rest, and only becomes abnormal when heart muscle
ischemia is brought on by exertion. Therefore, exercise treadmill or
bicycle testing (stress tests) are useful screening tests for patients with
significant coronary artery disease (CAD) and a normal resting EKG.
These stress tests are 60 to 70% accurate in diagnosing significant
CAD.
If the stress tests are not diagnostic, a nuclear agent (Cardiolite® or
thallium) can be given intravenously during stress tests. Addition of one
of these agents allows imaging of the blood flow to different regions of
the heart, using an external camera. An area of the heart with reduced
blood flow during exercise, but normal blood flow at rest, signifies
substantial artery narrowing in that region.
Stress echocardiography combines echocardiography (
ultrasound imaging of the heart muscle) with exercise
stress testing. It is also an accurate technique for
detecting CAD. When a significant narrowing exists, the
heart muscle supplied by the narrowed artery does not
contract as well as the rest of the heart muscle. Stress
echocardiography and thallium stress tests are 80% to
85% accurate in detecting significant CAD.
When a patient cannot undergo an exercise stress test
because of neurological or arthritic difficulties,
medications can be injected intravenously to simulate the
stress on the heart normally brought on by exercise.
Heart imaging can be performed with either a nuclear
camera or echocardiography.
 Cardiac catheterization with angiography (coronary
arteriography) is a technique that allows x-ray pictures to be taken
of the coronary arteries. It is the most accurate test to detect
coronary artery narrowing. Small hollow plastic tubes (catheters)
are advanced under x-ray guidance to the openings of coronary
arteries. Iodine contrast "dye" is then injected into the arteries
while an x-ray video is recorded. Coronary arteriography gives the
doctor a picture of the location and severity of narrowed artery
segments. This information is important in helping the doctor
select medications, PCI, or coronary artery bypass graft surgery
(CABG) as the preferred treatment option.
A newer, less invasive technique is the availability of high speed
CT coronary angiography. While it still involves radiation and dye
exposure, no catheters are needed in the arterial system, which
does decrease the risk of the procedure somewhat. This is a very
new modality, and its role in the evaluation and management of
CAD is still evolving. It is important to remember that risk of
serious complications from conventional coronary angiography is
very low (well under 1%).
How is CAD treated?
Angina medications reduce the heart muscle's demand for
oxygen in order to compensate for the reduced blood supply, and
also may partially dilate the coronary arteries to enhance blood
flow. Three commonly used classes of drugs are the nitrates,
beta blockers, and calcium blockers. Examples of nitrates include
isosorbide (Isordil), isosorbide mononitrate (Imdur), and
transdermal nitrate patches. Examples of beta blockers include
propranolol (Inderal),atenolol (Tenormin), and metoprolol (
Lopressor). Examples of calcium blockers include nifedipine (
Procardia, Adalat),verapamil, (Calan, Verelan, Verelan PM,
Isoptin, Isoptin SR, Covera-HS), diltiazem (Cardizem, Dilacor,
Tiazac), and amlodipine (Norvasc). Many patients benefit from
these angina medications and experience reduction of angina
during exertion. When significant ischemia still occurs, either with
ongoing symptoms or with exercise testing, coronary
arteriography is usually performed, often followed by either PCI or
CABG.
Patients with unstable angina have severe coronary artery
narrowing and often are at imminent risk of heart attack. In addition
to angina medications, they are given aspirin and the intravenous
blood thinner, heparin. A form of heparin, enoxaparin (Lovenox),
may be administered subcutaneously, and has been demonstrated
to be as effective as intravenous heparin in patients with unstable
angina. Aspirin prevents clumping of blood clotting elements called
platelets, while heparin prevents blood from clotting on the surface
of plaques. Newer potent IV anti platelet agents ("super aspirins")
are also available to help initially stabilize such patients. While
patients with unstable angina may have their symptoms temporarily
controlled with these potent medications, they are often at risk for
the development of heart attacks. For this reason, many patients
with unstable angina are referred for coronary angiography, and
possible PCI or CABG.
PCI can produce excellent results in carefully selected patients who
may have one or more severely narrowed artery segments which
are suitable for balloon dilatation, stenting, or atherectomy. During
PCI, a local anesthetic is injected into the skin over the artery in the
groin or arm. The artery is punctured with a needle and a plastic
sheath is placed into the artery. Under x-ray guidance (fluoroscopy),
a long, thin plastic tube, called a guiding catheter, is advanced
through the sheath to the origin of the coronary artery from the
aorta. A contrast dye containing iodine is injected through the
guiding catheter so that x-ray images of the coronary arteries can
be obtained. A small diameter guide wire (0.014 inches) is threaded
through the coronary artery narrowing or blockage. A balloon
catheter is then advanced over the guide wire to the site of the
obstruction. This balloon is then inflated for about one minute,
compressing the plaque and enlarging the opening of the coronary
artery. Balloon inflation pressures may vary from as little as one or
two atmospheres of pressure, to as much as 20 atmospheres.
Finally, the balloon is deflated and removed from the body.
Intracoronary stents are deployed in either a self-expanding fashion, or
most commonly they are delivered over a conventional angioplasty
balloon. When the balloon is inflated, the stent is expanded and
deployed, and the balloon is removed. The stent remains in place in
the artery. Atherectomy devices are inserted into the coronary artery
over a standard angioplasty guide wire, and then activated in varying
fashion, depending on the device chosen.
CABG surgery is performed to relieve angina in patients whose illness
has not responded to medications and are not good candidates for
balloon angioplasty. CABG is best performed in patients with multiple
blockages in multiple locations, or when blockages are located in
certain arterial segments which are not well-suited for PCI. CABG is
often also used in patients who have failed to attain long-term success
following one or more PCI procedures. CABG surgery has been
shown to improve long- term survival in patients with significant
narrowing of the left main coronary artery, and in patients with
significant narrowing in multiple arteries, especially in those with
decreased heart muscle pump function.
PTCA/Stent Procedure
Pre-Admission and Evaluation
You will first undergo a thorough evaluation by your
physician. Any questions you still have before your
procedure begins can be answered at this time. You may be
permitted clear liquids in the morning of the procedure.
However, this should be cleared with your physician first
. Otherwise, food and beverages may be withheld after
midnight. If you are a diabetic, you will be given special
instructions. Your groin area will be washed and shaved in
preparation for the PTCA/Stent.
Angioplasty Procedure
If family or friends are with you, they will wait in the waiting room near the
catheterization laboratory. The length of the procedure depends on the
complexity of each individual's situation, but in general, the duration is
between 1 and 2 hours.
An intravenous line will be started in your arm this morning. You will
receive various medications in the angioplasty laboratory though this
line. To help you relax, you will be given medication prior to leaving for
the lab. You will remain awake, but slightly drowsy.

You will be placed on an x-ray table upon your arrival in the lab. It is the
same type of room in which you had your cardiac catheterization. All
personnel in the lab will be wearing surgical attire. You will be covered by
sterile sheets, and so will some of the equipment. Your groin (arm) will
be cleansed with an antiseptic (might be cold) and then numbed with an
anesthetic. You will feel the sting of the needle, but then your groin (arm)
will feel quite numb. Heart monitoring equipment will be placed on your
arms and legs, and you may be given oxygen to breathe. You will be
given certain medications through the intravenous line, and periodically
medication will be given to relax you and decrease any restlessness.
Remember, you must still be able to talk and follow directions.
 The angioplasty catheter (balloon-tipped) is inserted at the numb
area, and advanced to your heart, using x-ray to guide it. When the
balloon is inflated at the point of the blockage, you may feel chest
pressure, or discomfort, and this is normal. It will subside when the
balloon is deflated. You may also feel your heart thump or skip, feel
flushed, or have a headache. All these sensations are normal. You
will be asked at times to hold your breath for a few seconds.
You may also be asked to cough.
After the procedure, you will be moved to a recovery area for a short
time, and then taken to your room where your heart can be
monitored. Nurses will closely monitor your vital signs and general
well being. They will also frequently check the groin area and
dressing. A small, flexible catheter is routinely left in the groin for 4-6
hours unless a percutaneous suture is used to close the hole. You
will be required to remain in bed and keep your leg immobilized.
You will be able to eat as soon as you wish after the procedure.
If family or friends are with you, they will wait
in the waiting room near the catheterization
laboratory. The length of the
procedure depends on the complexity of
each individual's situation, but in general, the
duration is between 1 and 2 hours.
An intravenous line will be started in your
arm this morning. You will receive various
medications in the angioplasty
laboratory though this line. To help you relax,
you will be given medication prior to leaving
for the lab. You will remain awake, but
slightly drowsy.
You will be placed on an x-ray table upon your arrival
in the lab. It is the same type of room in which you had
your cardiac catheterization. All personnel in the lab will be
wearing surgical attire. You will be covered by sterile
sheets, and so will some of the equipment. Your groin
(arm) will be cleansed with an antiseptic (might be cold)
and then numbed with an anesthetic. You will feel the sting
of the needle, but then your groin (arm) will feel quite
numb. Heart monitoring equipment will be placed on your
arms and legs, and you may be given oxygen to breathe.
You will be given certain medications through the
intravenous line, and periodically medication will be given
to relax you and decrease any restlessness. Remember,
you must still be able to talk and follow directions.
The angioplasty catheter (balloon-tipped) is inserted at
the numb area, and advanced to your heart, using x-ray
to guide it. When the balloon is inflated at the point of
the blockage, you may feel chest pressure, or
discomfort, and this is normal. It will subside when the
balloon is deflated. You may also feel your heart thump
or skip, feel flushed, or have a headache. All these
sensations are normal. You will be asked at times to
hold your breath for a few seconds. You may also be
asked to cough.
 After the procedure, you will be moved to a recovery
area for a short time, and then taken to your room where
your heart can be monitored. Nurses will closely monitor
your vital signs and general well being. They will also
frequently check the groin area and dressing. A small,
flexible catheter is routinely left in the groin for 4-6 hours
unless a percutaneous suture is used to close the hole.
You will be required to remain in bed and keep your leg
immobilized.
You will be able to eat as soon as you wish after the
procedure.
Recuperation
The catheter or sheath will be removed approximately 4-
6 hours after theprocedure is over. This waiting period is
crucial as the physician uses blood -thinning agents to
implant the stent, thus the sheaths cannot be removed
until the blood thinning reverted back to normal and firm
presssure applied for about 20 minutes. Then a pressure
bandage is applied and a small sandbag placed over it.
This is to assure proper healing of the artery. Pain
medication is available to you every few hours after the
procedure. Please let your nurse know of any pain or
discomfort you may feel at any time. The rest of the day
is basically for rest, recuperation, and a gradual return to
your activities.
 POSSIBLE
COMPLICATIONS
AND RISK
No invasive procedure occurs without a certain amount of potential risk
and complications. You are followed closely by your doctor and nurses,
precisely for the reason that if any of these complications arise,
corrective action can be taken immediately. The incidence of
complications is low, but nonetheless, you need to be aware what they
can be:

Severe bruising/bleeding into the groin area of the procedure leg.

Changes in your heart rhythm.
Allergic reaction to the contrast or dye or to other medications used.
A tear in the lining of the artery which is being dilated.
Possibility of a heart attack during or following inflation of the balloon or
stent implantation.. (you are given strong blood thinners to minimize this
risk.)
Possibility of a blood clot in the artery in which the catheter is inserted. (If
this occurs, surgical removal may be required.)
PCI, using balloons, stents, and/or atherectomy can achieve effective
relief of coronary arterial obstruction in 90% to 95% of patients. In a very
small percentage of patients, PCI cannot be performed because of
technical difficulties. These difficulties usually involve the inability to pass
the guide wire or the balloon catheter across the narrowed artery
segments. The most serious complication of PCI results when there is an
abrupt closure of the dilated coronary artery within the first few hours
after the procedure. Abrupt coronary artery closure occurs in 5% of
patients after simple balloon angioplasty, and is responsible for most of
the serious complications related to PCI. Abrupt closure is due to a
combination of tearing (dissection) of the inner lining of the artery, blood
clotting (thrombosis) at the balloon site, and constriction (spasm) or
elastic recoil of the artery at the balloon site.
To help prevent the process of thrombosis during or after PCI, aspirin is
given to prevent platelets from adhering to the artery wall and
stimulating the formation of blood clots. Intravenous heparin is given to
further prevent blood clotting; and combinations of nitrates and calcium
blockers are used to minimize vessel spasm. Individuals at an
increased risk for abrupt closure include:
women,
patients with unstable angina, and
patients having heart attacks.
The incidence of abrupt occlusion after PCI has declined dramatically
with the introduction of coronary stents, which essentially eliminate the
problem of flow-limiting arterial dissections, elastic recoil, and spasm.
The use of new intravenous "super aspirins", which alter platelet
function at a site different from the site of aspirin-inhibition, have
dramatically reduced the incidence of thrombosis after balloon
angioplasty and stenting. Examples of these newer agents include
abciximab (Reopro) and eptifibatide (Integrilin); these agents represent
a major advance in enhancing the safety and efficacy of PCI in selected
patients.
When despite these measures, a coronary artery cannot be "kept
open" during PCI, emergency CABG surgery may be necessary.
Before the advent of stents and advanced anti-thrombotic strategies,
emergency CABG following a failed PCI was required in as many as
5% of patients. In the current era, the need for emergent CABG
following PCI is less than 1-2%.The overall acute mortality risk
following PCI is less than one percent; the risk of a heart attack
following PCI is only about 1-2%. The degree of risk is dependent on
the number of diseased vessels treated, the function of the heart
muscle, and the age and clinical condition of the patient.
How do patients recover
after PCI?
PCI is performed in a special room fitted with
computerized x-ray equipment called a cardiac
catheterization laboratory. Patients are mildly sedated
with small amounts ofdiazepam (Valium), midazolam
(Versed), morphine, and other sedative narcotics
given intravenously. Patients may experience minor
discomfort at the site of the puncture in the groin or
the arm. Patients also may experience brief episodes
of angina while the balloon is inflated, briefly blocking
the flow of blood in the coronary artery. The PCI
procedure can last from 30 minutes to two hours, but
is usually completed within 60 minutes.
 Patients are then brought to a monitored bed for observation. The
plastic catheters left in the artery are removed from the groin after four
to 12 hours depending on how long blood thinning is needed to
stabilize the opened artery. When these catheters are removed, the
area is compressed by hand or with the aid of a mechanical clamp for
about 20 minutes to prevent bleeding. In many instances, the artery in
the groin may be sutured or "sealed" in the catheterization laboratory,
and the catheters are immediately removed. This enables the patient to
sit up in bed within a few hours after the procedure.
Most patients are discharged home the day after PCI. Patients are
advised not to lift anything heavier than 20 pounds or perform vigorous
exertion for the first one to two weeks after PCI. This allows the area in
the coronary artery as well as the groin or arm arteries to heal. Patients
may return to normal work and sexual activity two or three days after
PCI.
 Patients are maintained on aspirin indefinitely after PCI to prevent future
thrombotic events [(for example, unstable angina or heart attack). In patients
who receive stents, an additional anti-platelet agent (in most instances
clopidogrel (Plavix)] is given in conjunction with aspirin for two to four weeks;
this is because the metal in the stents may promote the formation of blood
clots in the first couple of weeks after the stent is inserted. After two weeks,
the metal of the stent is coated with a natural tissue lining which no longer
stimulates platelets to form blood clots. With the newer medicated stents
designed to prevent recurrence, the process of forming this natural lining may
be delayed, and aspirin and Plavix are generally continued for a year or
longer. If you have a stent, always consult your cardiologist before stopping
aspirin or Plavix, even for a few days.
Exercise stress testing is sometimes done several weeks after PCI and
signals the beginning of a cardiac rehabilitation program. Rehabilitation can
involve a 12 week program of gradually increasing monitored exercise lasting
one hour three times a week. Lifestyle changes can help to lower the patient's
chance of developing further coronary artery disease. These include
stopping smoking, reducing weight and dietary fat, controlling blood pressure
and diabetes, and lowering blood cholesterol levels. Cholesterol reduction is
often aided by the addition of medications which may not only lower
cholesterol levels, but may offer protection against future heart attacks.
What are the long-term results of
PCI?
Long-term benefits of PCI depend on the maintenance of the newly-
opened coronary artery(ies). 30-50% of patients with successful balloon
angioplasty (no stent) may develop recurrent narrowing (restenosis) at the
site of the balloon inflation, usually within six months following PCI.
Patients may complain of recurrence of angina or may have no symptoms.
Restenosis is often detected by exercise stress tests performed at four to
six months after PCI. Restenosis occurs with a significantly higher
frequency in patients with diabetes. The rate of restenosis is greater in
vein grafts, at the origins of vessels, in the beginning part of the left
anterior descending coronary artery, and in those with suboptimal initial
results. The widespread use of intracoronary stents has reduced the
incidence of restenosis by as much as 50% or more; this is due to
prevention of "elastic recoil" in the artery, as well as providing a larger
initial channel in the treated artery. With the newer medicated stents, the
restenosis rate is well under 10%.
Restenosis can simply be observed or treated with medications if the
narrowing is not critical and the patient is not symptomatic. Some patients
undergo a repeat PCI to increase coronary artery blood flow. Second PCI
procedures have similar initial and long-term results as first procedures,
although certain patterns of restenosis have a very high repeat recurrence
rate. Sometimes, CABG surgeries are recommended for those patients
who have developed more extensive disease in the restenosed artery as
well as in the other coronary arteries. Patients may also choose CABG
surgery to avoid the uncertainty of restenosis after the second PCI. In
patients with restenosis after balloon angioplasty or stents, the use of
intracoronary radiation (brachytherapy) may reduce the risk of future
restenosis. If no evidence of restenosis is observed after six to nine
months, studies have demonstrated that the treated arterial segment is
likely to remain open for many years. "Late restenosis" after one year or
more is very uncommon. Symptoms developing more than one year after
successful PCI are usually due to blockage in a different segment of the
artery, or in a different artery from that which was treated in the initial PCI.
Follow-up Care
 Periodic follow-up with your personal physician is quite
important. It is important for you to realize that by
angioplasty (PTCA), your immediate problem has been
taken care of, but it does not cure coronary artery disease.
In some patients, re -narrowing (Restenosis) of the artery
may occur over the ensuing 3-6 months. If this happens,
your original symptoms may return, or your stress test will
be abnormal.
If you have chest discomfort, stop your activity, sit or
lie down, and take nitroglycerine, as instructed. If the chest
discomfort does not go away after 3 nitrolycerin tablets in a
15 minute period, DO NOT DELAY SEEKING MEDICAL
ATTENTION. Either call your doctor, or go to an
emergency room.
 Coronary Balloon
Angioplasty At A Glance
 Coronary angioplasty is accomplished using a balloon-tipped
catheter inserted through an artery in the groin or arm to enlarge a
narrowing in a coronary artery.
Coronary artery disease occurs when cholesterol plaque builds up
(arteriosclerosis) in the walls of the arteries to the heart.
Angioplasty is successful in opening coronary arteries in well over
90% of patients.
Up to 30-40% of patients with successful coronary angioplasty will
develop recurrent narrowing at the site of balloon inflation.
The use of newer devices such as intracoronary stents and
atherectomy, as well as newer pharmacologic agents has resulted in
higher success rates, reduced complications, and reduced
recurrence after PCI.