Angioplasty and Stent Placement for the Heart

Angioplasty is a procedure used to
open blocked coronary arteries caused by coronary artery disease. It restores blood flow
to the heart muscle without open-heart surgery. Angioplasty can be done in an emergency
setting such as a heart attack. Or it can be done as elective surgery if your healthcare
provider strongly suspects you have heart disease. Angioplasty is also called
percutaneous coronary intervention (PCI).

For angioplasty, a long, thin tube
(catheter) is put into a blood vessel and guided to the blocked coronary artery. The
catheter has a tiny balloon at its tip. Once the catheter is in place, the balloon is
inflated at the narrowed area of the heart artery. This presses the plaque or blood clot
against the sides of the artery, making more room for blood flow.

The healthcare provider uses
fluoroscopy during the surgery. Fluoroscopy is a special type of X-ray that’s like an
X-ray “movie.” It helps the doctor find the blockages in the heart arteries as a
contrast dye moves through the arteries. This is called coronary angiography.

The healthcare provider may decide
that you need another type of procedure. This may include removing the plaque
(atherectomy) at the site of the narrowing of the artery. In atherectomy, the provider
may use a catheter with a a rotating tip. When the catheter reaches the narrowed spot in
the artery, the plaque is broken up or cut away to open the artery.


Angioplasty, showing artery with catheter, plaque, balloon and guidewire

Stents


Stent placement

Stents

Coronary stents are now used in
nearly all angioplasty procedures. A stent is a tiny, expandable metal mesh coil. It
is put into the newly opened area of the artery to help keep the artery from
narrowing or closing again.

Once the stent has been placed,
tissue will start to coat the stent like a layer of skin. The stent will be fully
lined with tissue within 3 to 12 months, depending on if the stent has a medicine
coating or not. You may be prescribed medicines called antiplatelets to decrease the
“stickiness” of platelets. Platelets are special blood cells that clump together to
stop bleeding. The medicine can also prevent blood clots from forming inside the
stent. Your healthcare team will give specific instructions on which medicines need
to be taken and for how long.

Most stents are coated with
medicine to prevent scar tissue from forming inside the stent. These stents are
called drug-eluting stents (DES). They release medicine within the blood vessel that
slows the overgrowth of tissue within the stent. This helps prevent the blood vessel
from becoming narrow again. . Some stents don’t have this medicine coating and are
called bare metal stents (BMS). They may have higher rates of stenosis, but they
don’t require long-term use of antiplatelet medicines. This may be the preferred
stent in people who are at high risk of bleeding.

Because stents can become
blocked, it’s important to talk with your healthcare team about what you need to do
if you have chest pain after a stent placement.

If scar tissue does form inside
the stent, you may need a repeat procedure. This may be using either balloon
angioplasty or with a second stent. In some cases, radiation therapy may be given
through a catheter placed near the scar tissue to stop the growth of scar tissue and
open up the vessel. This is called brachytherapy.

Angioplasty is done to restore
coronary artery blood flow when the narrowed artery is in a place that can be reached in
this manner. Not all coronary artery disease (CAD) can be treated with angioplasty. Your
doctor will decide the best way to treat your CAD based on your circumstances.


Normal heart and heart with CAD

Possible risks linked to
angioplasty, stenting, atherectomy, and related procedures include:

  • Bleeding at the site where the catheter is put into the body (usually the groin, wrist, or arm)
  • Blood clot or damage to the blood vessel from the catheter
  • Blood clot within the treated blood vessel
  • Infection at the catheter insertion site
  • Abnormal heart rhythms
  • Heart attack
  • Stroke
  • Chest pain or discomfort
  • Rupture of the coronary artery or
    complete closing of the coronary artery, needing open-heart surgery
  • Allergic reaction to the contrast dye used
  • Kidney damage from the contrast dye

You may want to ask your healthcare
team about the amount of radiation used during the procedure and the risks related to
your particular situation. It’s a good idea to keep a record of your radiation exposure,
such as previous scans and other types of X-rays, so that you can tell your healthcare
team. Risks linked to radiation exposure may be related to the total number of X-rays or
treatments over a long period.

For some people, having to lie still on the procedure table for the length of the procedure may cause some discomfort or pain.

There may be other risks depending
on your specific health condition. Discuss any concerns with your healthcare team before
the procedure.

  • Your healthcare team will explain the
    procedure to you and you can ask questions.
  • You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if anything is unclear.
  • Tell your healthcare team if you have
    ever had a reaction to any contrast dye, or if you are allergic to iodine.
  • Tell your healthcare team if you are
    sensitive to or are allergic to any medicines, latex, tape, and local or general
    anesthesia.
  • Follow any directions you are given
    for not eating or drinking before surgery.
  • Tell your healthcare team if you are
    pregnant or think you could be. Radiation exposure during pregnancy may lead to birth
    defects.
  • Tell your healthcare team if you have
    any body piercings on your chest or belly (abdomen).
  • Tell your healthcare team of all
    prescription and over-the-counter medicines, vitamins, herbs, and supplements that
    you are taking.
  • Tell your healthcare team if you have
    a history of bleeding disorders or if you are taking any blood-thinning medicines
    (anticoagulant or antiplatelet), aspirin, or other medicines that affect blood
    clotting. You may need to stop some of these medicines before the procedure. But for
    planned angioplasty procedures, your doctor may want you to continue taking aspirin
    and antiplatelet medicines, so be sure to ask.
  • Your provider may request a blood test
    before the procedure to find out how long it takes your blood to clot.  Other blood
    tests may be done as well.
  • Tell your healthcare team if you have
    a pacemaker or other implanted device.
  • You may get a sedative before the procedure to help you relax.
  • Based on your health condition, your
    doctor may give you other instructions on how to get ready.

Angioplasty may be done as part of
your stay in a hospital. Procedures may vary depending on your condition and your
doctor’s practices. Most people who have angioplasty and stent placement are monitored
overnight in the hospital.


Catheter placement

Generally, angioplasty follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear your dentures or hearing aid if you use either of these.
  2. You will be asked to remove your clothing and will be given a gown to wear.
  3. You will be asked to empty your bladder before the procedure.
  4. If there is a lot of hair at the area of the catheter insertion (often the groin area), the hair may be shaved off.
  5. An IV (intravenous) line will be
    started in your hand or arm before the procedure. It will be used for injection of
    medicine and to give IV fluids, if needed.
  6. You will be placed on your back on the procedure table.
  7. You will be connected to an electrocardiogram (ECG) monitor that records the electrical activity of your heart and monitors your heart rate using electrodes that stick to your skin. Your vital signs (heart rate, blood pressure, breathing rate, and oxygen level) will be monitored during the procedure.
  8. There will be several monitor screens in the room, showing your vital signs, the images of the catheter being moved through your body into your heart, and the structures of your heart as the dye is injected.
  9. You will get a sedative in your IV to help you relax. However, you will likely stay awake during the procedure.
  10. Your pulses below the catheter insertion site will be checked and marked so that the circulation to the limb below the site can easily be checked during and after the procedure.
  11. Local anesthesia will be injected into
    the skin at the insertion site. This may be in your leg, arm, or wrist. You may feel
    some stinging at the site for a few seconds after the local anesthetic is
    injected.
  12. Once the local anesthesia has taken
    effect, a sheath, or introducer, will be put into the blood vessel (often at the
    groin). This is a plastic tube through which the catheter will be threaded into the
    blood vessel and advanced into the heart.
  13. The catheter will be threaded through
    the sheath into the blood vessel. The doctor will advance the catheter through the
    aorta into the heart. Fluoroscopy will be used to help see the catheter advance into
    the heart.
  14. The catheter will be threaded into the coronary arteries. Once the catheter is in place, contrast dye will be injected through the catheter into your coronary arteries in order to see the narrowed area(s). You may feel some effects when the contrast dye is injected into the IV line. These effects include a flushing sensation, a salty or metallic taste in the mouth, or a brief headache. These effects usually last only a few moments.
  15. Tell your doctor if you feel any breathing trouble, sweating, numbness, itching, nausea or vomiting, chills, or heart palpitations.
  16. After the contrast dye is injected, a series of rapid X-ray images of the heart and coronary arteries will be taken. You may be asked to take in a deep breath and hold it for a few seconds during this time.
  17. When the doctor locates the narrowed artery, the catheter will be advanced to that location and the balloon will be inflated to open the artery. You may have some chest pain or discomfort at this point because the blood flow is temporarily blocked by the inflated balloon. Any chest discomfort or pain should go away when the balloon is deflated. However, if you notice any continued discomfort or pain, such as chest pain, neck or jaw pain, back pain, arm pain, shortness of breath, or breathing trouble, tell your doctor right away.
  18. The doctor may inflate and deflate the balloon several times. The decision may be made at this point to put in a stent to keep the artery open. In some cases, the stent may be put into the artery before the balloon is inflated. Then the inflation of the balloon will open the artery and fully expand the stent.
  19. The doctor will take measurements, pictures, or angiograms after the artery has been opened. Once it has been determined that the artery is opened sufficiently, the catheter will be removed.
  20. The sheath or introducer is taken out and the insertion site may be closed with a closure device that uses collagen to seal the opening in the artery, by the use of sutures, or by applying manual pressure over the area to keep the blood vessel from bleeding. Your doctor will decide which method is best for you.
  21. If a closure device is used, a sterile dressing will be applied to the site. If manual pressure is used, the doctor (or an assistant) will hold pressure on the insertion site so that a clot will form on the outside of the blood vessel to prevent bleeding. Once the bleeding has stopped, a very tight bandage will be placed on the site.
  22. Staff will help you slide from the
    table onto a stretcher so that you can be taken to the recovery area. NOTE: If the
    insertion was in the groin, you will not be allowed to bend your leg for several
    hours. If the insertion site was in the arm, your arm will be kept elevated on
    pillows and kept straight by placing your arm in an arm guard (a plastic arm board
    designed to immobilize the elbow joint). In addition, a plastic band (that works like
    a belt around the waist) may be secured around your arm near the insertion site. The
    band will be loosened at given intervals and then removed when your doctor decides
    the pressure is no longer needed.

In the hospital

After the procedure, you may be
taken to the recovery room for observation or returned to your hospital room. You
will stay flat in bed for several hours after the procedure. A nurse will monitor
your vital signs, the insertion site, and circulation and sensation in the affected
leg or arm.

Tell your nurse right away if
you feel any chest pain or tightness, or any other pain, as well as any feelings of
warmth, bleeding, or pain at the insertion site.

Bed rest may vary from 2 to 6
hours depending on your specific condition. If your doctor placed a closure device,
your bed rest may be shorter.

In some cases, the sheath or
introducer may be left in the insertion site. If so, the bedrest will be last until
the sheath is removed. After the sheath is removed, you may be given a light
meal.

You may feel the urge to urinate
often because of the effects of the contrast dye and increased fluids. You will need
to use a bedpan or urinal while on bed rest so that your affected leg or arm will not
be bent.

After the specified period of
bed rest has been completed, you may get out of bed. The nurse will help you the
first time you get up, and will check your blood pressure while you are lying in bed,
sitting, and standing. You should move slowly when getting up to avoid any dizziness
from the long period of bed rest.

You may be given pain medicine
for pain or discomfort at the insertion site or from having to lie flat and still for
a long time.

You will be encouraged to drink
water and other fluids to help flush the contrast dye from your body.

You may go back your usual diet
after the procedure, unless your doctor decides otherwise.

You will most likely spend the
night in the hospital after your procedure. Depending on your condition and the
results of your procedure, your stay may be longer. You will get detailed
instructions for your discharge and recovery period.

At home

Once at home, monitor the
insertion site for bleeding, unusual pain, swelling, abnormal discoloration, or
temperature change. A small bruise is normal. If you notice a constant or large
amount of blood at the site that can’t be contained with a small dressing, tell your
healthcare team.

If your doctor used a closure
device at your insertion site, you will be given specific information regarding the
type of closure device that was used and how to take care of the site. There will be
a small knot, or lump, under the skin at the site. This is normal. The knot should
slowly disappear over a few weeks.

It will be important to keep the
insertion site clean and dry. Your healthcare team will give you specific bathing
instructions. In general, don’t use a bathtub or hot tub or go swimming until the
skin has healed.

You may be advised not to
participate in any strenuous activities. Your healthcare team will instruct you about
when you can return to work and resume normal activities.

Tell your healthcare team if you
have any of the following:

  • Fever or chills
  • Increased pain, redness, swelling,
    bleeding, or other drainage from the insertion site
  • Coolness, numbness or tingling, or
    other changes in the affected arm or leg
  • Chest pain or pressure, nausea or
    vomiting, profuse sweating, dizziness, or fainting

Your doctor may give you other
instructions after the procedure, depending on your particular situation.

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications are
  • What would  happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how you will get the
    results
  • Who to call after the test or procedure if you have questions or problems
  • How much you will have to pay for the
    test or procedure