Angioplasty

Angioplasty, also called percutaneous transluminal coronary angioplasty or PTCA, is a procedure used to treat coronary artery disease (CAD) with angina (chest pain). To improve blood flow to the heart, the doctor places an inflatable balloon catheter (hollow tube) into a narrowed coronary artery.

Angioplasty can relieve chest pain and improve quality of life. The procedure doesn't cure CAD, however. The arteries may narrow again after treatment.


Understanding heart disease
The coronary arteries supply oxygen and nutrient-rich blood to your heart. When the coronary arteries become narrowed or blocked with plaque (a buildup of fatty material), your heart may not receive enough blood to keep pumping. This condition is known as atherosclerosis (hardening of the arteries).
Atherosclerosis is the most common cause of coronary artery disease. It can lead to chest pain or even a heart attack, also known as a myocardial infarction or MI. A poor diet can contribute to plaque formation. Smoking, heredity and certain medical conditions, such as diabetes or high blood pressure, may also play a role.


Purpose
Coronary angioplasty is used to open narrowed portion(s) of the coronary arteries.

Indications
Angioplasty may be an option if medication doesn't control your chest pain or the blockage is severe. It's also used to treat coronary artery blockages after a heart attack. The doctor will also consider the following factors:
the number of narrowed coronary arteries, as well as how many narrowed areas are in each artery and their length
the condition of the heart muscle beyond the narrowed area
how long you've had chest pain or heart disease
the general ability of the heart to function
the presence of other medical illnesses or risk factors for surgery
the number of prior angioplasty treatments or coronary artery bypass surgeries (surgery that reroutes the blood around the obstructions in the coronary arteries)
The expected result of angioplasty is improved blood flow through the coronary arteries. Once blood flow is restored to the heart, chest pain usually decreases.

Traditionally, the procedure was used most often for people who had narrowing in single or double arteries. With advanced technology, however, coronary angioplasty is being used to treat narrowing in multiple arteries in some cases.

Angioplasty is used less often to treat left main stenosis (narrowing in the left coronary artery -- the main source of blood to the left ventricle, the main pumping chamber of the heart -- that affects or blocks the blood flow to these areas). It's often less successful when done on the vein grafts used for coronary artery bypass surgery.


Patient preparation
Your doctor will give you specific instructions to help you prepare for the procedure. Arrange for someone to help you at home while you recover. Be sure you understand the risks and benefits of angioplasty before you sign the consent form. Thoroughly discuss any questions you may have with the doctor who'll be doing the procedure.
Before the procedure, you may need blood tests, an electrocardiogram (a recording of the electrical activity of the heart) or a chest X-ray. Typically, you'll be asked not to eat or drink after midnight the night before the procedure.

On the day of the procedure, you'll be sedated with some type of intravenous medication. Small electrode pads will be placed on your chest to help the doctor monitor your heart during the procedure.


Procedure
Coronary angioplasty is similar to a coronary angiogram (heart catheterization) used to diagnose coronary artery narrowing. In fact, informed consent is usually given for both procedures in case an angioplasty becomes necessary during an angiogram.
The site where the catheter will be inserted (typically the groin or, rarely, the arm) will be scrubbed and draped with a sterile cloth. A local anesthetic will be used to numb the area. Then, the doctor will make a small incision and thread the catheter into a major artery. The catheter will follow the artery toward the left chamber of the heart. You shouldn't feel the catheter moving since there are no nerve or pain fibers inside the artery.

At this point, the doctor will be able to see the coronary arteries and the blockage on a monitor in the operating room with the help of a small amount of radiopaque dye (dye that will also appear on an X-ray) injected through the catheter.

Next, a smaller catheter with a balloon at its tip will be inserted into the original guide catheter. When the balloon catheter gets to the narrowed or blocked area, the balloon will be inflated with a small amount of contrast for 30 to 120 seconds. This widens the blocked part of the coronary artery. Sometimes, the balloon splits apart the blockage. Several inflations are often needed. Each time the balloon is inflated, you may feel some chest pain. The discomfort is expected to go away when the balloon is deflated.

Often, a stent (a stainless steel mesh tube) is needed to hold the coronary artery open. The stent will remain permanently imbedded against the affected blood vessel after the balloon is deflated and removed.

The procedure usually takes 30 to 90 minutes. After the balloon catheter is removed, angiograms (special imaging studies) will be repeated to determine if blood flow to the affected coronary artery has improved.


Postprocedure care
For 12 to 24 hours after the procedure, your heart rate, rhythm and vital signs will be closely monitored. Once the catheter is removed, a pressure dressing and a sand bag or other pressure device will be applied to the area to reduce the risk of bleeding. Since an artery is involved, prolonged pressure may be needed. The medical staff will check the site often for any signs of bleeding. There's also a closure device that may be inserted to allow you to move shortly after the procedure. They'll also check your circulation through the pulses in your feet.
Depending on the doctor's orders, your bed may be kept in a nearly flat position for at least six hours to avoid putting any pressure on the spot where the catheter was inserted. The prolonged flat position is often the most uncomfortable aspect of angioplasty.

Some people go home the same day. Others need to stay in the hospital for a day or two. Long-term medication therapy is typically prescribed. For most people, this involves aspirin and another antiplatelet drug (such as clopidogrel) and a statin (a cholesterol-lowering medication), a beta blocker and an angiotensin-converting enzyme (ACE) inhibitor.


Benefits
Angioplasty can improve blood flow through the coronary arteries.
If you have an angioplasty as an emergency treatment for a heart attack, it can decrease the risk of having another one. The procedure is considered safer than treatment with thrombolytic (clot-busting) medications, and it can reduce the risk of dying in the first month after the heart attack. Angioplasty will also increase the odds of being able to resume your normal routine.

Angioplasty is less invasive than coronary artery bypass surgery, and the recovery time is faster. General anesthesia can be avoided, and removing a blood vessel from the leg or chest isn't necessary.

Angioplasty may be an option for people considering bypass surgery, as well as those who've already had bypass surgery.


Risks
About 30 to 40 percent of cleared blockages return within six months. A repeat angioplasty is often successful. The rate of repeat blockages after stent placement may be as low as 15 to 20 percent.
A medication-coated stent designed to further reduce a recurrent blockage was approved by the U.S. Food and Drug Administration (FDA) in 2003. Although side effects associated with these stents present a slight risk, original problems with the stents have largely been resolved through the use of medication and meticulous implantation technique. Another medication-coated stent is showing promising results in clinical trials.

Other risks of angioplasty may include:

an allergic reaction to the dye
excessive bleeding that may require treatment or a transfusion
spasm of the coronary artery
damage to the coronary artery that requires emergency bypass surgery
interrupted blood flow to the heart or area where the catheter is inserted, causing a heart attack
stroke
Rarely, complications of angioplasty may be fatal.

Angioplasty should be done in a facility where an open heart surgical team is available. According to reports in medical literature, fewer complications are reported in facilities that handle a large number of angioplasties.


Considerations
Based on long-term outcomes, the overall success rate of coronary angioplasty is high, even when repeat procedures are done. The success is higher when risk factors for heart disease are adequately addressed and treated, such as:
sedentary lifestyle
high cholesterol
high blood pressure
tobacco use
diabetes (People who have diabetes tend to have better results with coronary artery bypass surgery.)
Researchers haven't yet discovered how to entirely prevent coronary artery disease. Angioplasty is one treatment option, but repeat angioplasties may be needed. Some people may ultimately require coronary artery bypass surgery.

Advances in technology, equipment and medication therapy are constantly evolving. For example, a laser-tipped catheter to vaporize the plaque in narrowed arteries is now used alone and in combination with angioplasty.

A procedure known as atherectomy can be used to remove plaque using various types of catheters.

Brachytherapy, a technique in which doctors deliver brief amounts of radiation inside the coronary arteries using angioplasty or stents, can reduce the occurrence of recurrent blockages. New stent materials are also being researched.

Finally, new medications, such as antiplatelet medications, can reduce the risks associated with angioplasty.


Pregnancy-specific information
During pregnancy, balloon angioplasty may be recommended only under extreme circumstances -- if you develop unstable angina or have a heart attack, for example. Pregnancy doesn't increase the risks for the mother, but possible exposure to radiation may pose a risk for the baby. The risks may be less than with coronary bypass surgery, however.

Senior-specific information
The risk of coronary artery disease increases with age. Typically, men are diagnosed with the condition about 10 years earlier than women. Although being older doesn't pose a problem for having angioplasty, the risks due to the long-term effects of lifestyle habits, along with the increased prevalence of other diseases as you get older, can potentially complicate treatment measures.