Angioplasty with stent placement for heart attack and unstable angina

Treatment Overview

Angioplasty, also know as percutaneous coronary intervention (PCI) or percutaneous transluminal coronary angioplasty (PTCA), is a procedure in which a catheter-guided balloon is used to open a narrowed coronary artery. A stent (a wire-mesh tube that expands to hold the artery open) is usually placed at the narrowed section during angioplasty.

Angioplasty with stent placement has become the first choice of treatment for a heart attack if it can be performed in a timely manner. It is a common procedure in large medical centres in Canada.

The goal of this revascularization procedure is to increase blood flow to the heart muscle tissue by clearing out both the blood clot and cholesterol from a ruptured plaque that is blocking the blood vessel. Clot-dissolving drugs (thrombolytics) only remove the blood clot. Angioplasty/stenting is less invasive and has a shorter recovery time than bypass surgery, which requires open-heart surgery.

Angioplasty may be available only at certain regional medical centres. The treatment your doctor chooses may depend on how close you are to a regional centre and the time it would take to transport you to the centre for treatment.

After you are given a sedative, a thin flexible tube (catheter) is inserted through an artery in the groin or arm and carefully guided up the aorta into the blocked coronary artery. Usually, cardiac catheterization and coronary angiography are performed first to identify any blockages by injecting a dye that contains iodine. The dye makes the coronary arteries visible on a digital X-ray screen.

If there is a blockage, the catheter is advanced to the narrowed portion, and a small balloon at the end of the tube is inflated. The balloon may remain inflated from 20 seconds to 3 minutes, then it is deflated and removed. The pressure from the inflated balloon presses the plaque against the wall of the artery, creating more room for blood to flow. See a picture of a balloon angioplasty.

In most cases, a small, expandable wire-mesh stent is permanently inserted into the artery during angioplasty. The balloon is placed inside the stent and inflated, which opens the stent and pushes it into place against the artery wall to keep the narrowed artery open. Because the stent is mesh-like, the cells lining the blood vessel grow through and around the stent to help secure it. See a picture of stent placement. This procedure is designed to:

• Open up the artery and press the plaque against its walls, thereby improving blood flow.
• Keep the artery open after the balloon is deflated and removed.
• Seal any tears in the artery wall.
• Prevent the artery wall from collapsing or closing off again (restenosis).
• Prevent small pieces of plaque from breaking off, which might cause a heart attack.

View the slide show on angioplasty for coronary artery disease to see how the procedure is done.

Reclosure (restenosis) of the artery is much less likely to occur after stenting than with angioplasty alone. Stent placement is rapidly becoming the standard procedure during most angioplasty procedures. Drug-eluting stents are coated with medicines that prevent restenosis due to tissue regrowth. These coated stents are even more effective than standard stents in preventing the artery from closing again. Whether your doctor chooses to give you a drug-eluting stent will depend in part on whether you have any risk factors (such as diabetes) that make it more likely that your artery will narrow again, and whether your health would allow long-term dual antiplatelet therapy or another catheterization or coronary artery bypass graft surgery (CABG) at a later time, if needed.¹

What To Expect After Treatment

After angioplasty, you will be moved to a recovery room or to the coronary care unit. Your heart rate, pulse, and blood pressure will be closely monitored. You will have a large bandage or a compression device at the catheter insertion site to prevent bleeding.

Angioplasty procedures last about 1½ to 2 hours, although preparation and recovery times add to the total time. People usually can start walking within 12 to 24 hours after angioplasty. The average hospital stay is 1 to 2 days for uncomplicated procedures. You may resume exercise and driving after several days.

After angioplasty, you will take antiplatelet medicines to help prevent another heart attack or a stroke. You will probably take ASA plus another antiplatelet such as clopidogrel (Plavix). If you get a drug-eluting stent, you will probably take both of these medicines for at least one year. If you get a bare metal stent, you will take both medicines for at least one month but maybe up to one year. Then, you will likely take daily ASA long-term. If you have a high risk of bleeding, your doctor may shorten the time you take these medicines.

Why It Is Done

Although many factors are involved, angioplasty is most often used if you:

• Are having a heart attack.
• Have frequent or severe chest pain (angina) that is not responding to medicine.
• Have evidence of severely reduced blood flow (ischemia) to an area of heart muscle caused by one or more narrowed coronary arteries.
• Are in good enough health to have the procedure.

Angioplasty may not be a reasonable treatment option when:

• There is no evidence of reduced blood flow to the heart muscle.
• Only small areas of the heart are at risk, and you do not have disabling chest pain (angina).
• You are at risk for having complications or dying during angioplasty due to other health problems.
• The affected artery cannot be reached during angioplasty.
• The surgeon or hospital does not have extensive experience in performing these procedures.
• The hospital does not have access to emergency cardiac surgical facilities.

How Well It Works

Angioplasty relieves chest pain and improves blood flow to the heart. If the artery narrows again, another angioplasty or bypass surgery may be needed.

People who have angioplasty combined with stenting and certain medicines (glycoprotein IIb/IIIa platelet receptor antagonists such as abciximab) have better long-term outcomes compared with those who have angioplasty alone.² When used to repair one artery, angioplasty and bypass surgery have similar success rates.²

Emergency angioplasty with or without stenting is typically the first choice of treatment for a heart attack. When performed in hospitals where the staff had extensive experience with this procedure, angioplasty saved an extra 2 lives in every 100 people treated with angioplasty instead of thrombolytic therapy.³

Risks

Risks of angioplasty may include:

• Bleeding or bruising at the site where the catheter is inserted.
• Sudden closure of the repaired artery.
• Heart attack.
• A need for additional procedures. Angioplasty may increase the risk of needing urgent bypass surgery. In addition, if the repaired artery narrows again (restenosis), a repeat angioplasty may be needed.
• Death. The risk of death is higher when more than one artery is involved.

What To Think About

Studies show that angioplasty with stent placement, compared with angioplasty only, reduces the chance that the artery will renarrow and possibly reduces the risk of death.⁴ Drug-eluting stents further reduce the chance that the artery will renarrow. But experts do not know yet how safe the drug-eluting stents are over the long term or how well they work over the long term.

Angioplasty does not require open-chest surgery and has less risk for immediate complications. Long-term outcomes of bypass surgery versus angioplasty are similar.⁵ But bypass surgery may be a better option for some people, such as those with diabetes. Studies show that bypass surgery lowers the death rate in people who have diabetes and heart attack when compared with angioplasty or thrombolytic therapy.⁶

Bypass surgery may also be better for people who have extensive coronary atherosclerosis.² Additionally, bypass surgery may be the best option when there are blockages in the coronary arteries that cannot be reached during angioplasty or when angioplasty was tried but did not sufficiently widen the blood vessel.

If you smoke, the benefits of angioplasty are much greater if you quit smoking. Studies show that quality of life improves less and the risk of death is higher after coronary artery bypass surgery or angioplasty for people who continue to smoke than for those who do not smoke.⁷

For more information, see bypass surgery versus angioplasty.

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Author:	Robin Parks, MS	Last Updated: February 26, 2008
Medical Review:	Caroline S. Rhoads, MD - Internal Medicine Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology
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