Angioplasty

Angioplasty is a technique for reopening narrowed or blocked arteries in the heart (coronary arteries) without major surgery. First used in 1977, it's now as common as heart bypass surgery. It's sometimes called percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI).

"Angio" means relating to a blood vessel and "plasty" means repair. Angioplasty is also used in other parts of the body, usually to treat peripheral artery disease.

Before the operation

You shouldn't eat after midnight on the night before your angioplasty. Ask your doctor if you can drink clear liquids after midnight. You can usually continue to take your medications, but you should confirm this with your doctor. Check with your doctor if you take blood thinners such as warfarin, as you may need to stop them for a certain number of days before the procedure. If you take insulin, you may have to adjust the dose.

You must tell your doctor if you are allergic to iodine, since angioplasty involves injecting you with an iodine-based dye. You may have to go for some preliminary blood tests. Your doctor may tell you to not smoke for a period of time before or after angioplasty. For best results, you should quit smoking permanently.

The procedure

Angioplasty is performed while you are awake, under local anesthetic. It's sometimes uncomfortable, but not usually painful. The surgeon makes a small incision in the groin or arm and inserts a thin tube, called a catheter, into the artery. The catheter includes a small balloon and a small wire tube, called a stent. Once the catheter is in place, a dye is injected and X-rays are taken, which tell the physician exactly where the blockages are and how narrow the artery is. This is also known as an angiogram and functions as a map for the doctor.

The doctor will then inflate the balloon, opening the stent and pushing it against the artery wall. After the procedure is complete, the cells that line the blood vessel will grow around the stent, holding it in place. The whole procedure usually lasts 30 minutes but may last as long as several hours. Sometimes, people will have to return to get their arteries redone because of re-narrowing (restenosis) at the site of the balloon inflation.

There are other types of angioplasty sometimes used in combination with the balloon:

• Drug-eluting stents are specially-treated stents that gradually release a special medication into the wall of the artery after they have been put into place and inflated. They reduce the risk of needing another procedure and are used for people who have a high risk of developing re-narrowing of the artery after the initial procedure. These stents may increase the rare risk of clotting. Studies show that newer available drug-eluting stents are at least as safe as the bare-metal stents.

• Directional atherectomy involves using a miniature rotating blade to cut out the fatty deposit and remove it from the body.

• Excimer laser angioplasty uses a laser to remove the blockage in the artery. Usually, the balloon is used to help make the space through the blockage larger.

• In rotational atherectomy, a diamond-studded drill bit is used to pulverize tough blockages.

• Intracoronary radiation involves irradiation of the section of artery after balloon angioplasty to help prevent in-stent restenosis. Studies show this experimental technique can reduce restenosis in your arteries by up to 70%.

After the operation

After an angioplasty some people go home the same day, and some people are admitted to hospital and monitored overnight. They are usually sent home early the next day. Once home, you can startdoing routine activities after a few days, but should avoid any type of lifting or other strenuous physical activity for about 5 days or as long as your doctor advises. Your doctor will advise you when you will be able to return to work and resume driving and other physical activity.

If you have a stent, you will usually have to take an extra blood thinner medication such as clopidogrel* in addition to acetylsalicylic acid* for at least the first few months in order to prevent blood from clotting on the metal stent. This treatment may continue for one year. You may also have to put off dental work for several months due to the risk of endocarditis (an infection of the heart).

Call your doctor or hospital if you:

• experience swelling, bleeding, or pain at the insertion site

• develop a fever

• notice a change in temperature or colour in the arm or leg that was used

• feel faint or weak

• have shortness of breath or chest pain

Angioplasty or coronary artery bypass surgery?

Coronary artery bypass grafting (CABG) is a successful but more invasive technique for restoring blood flow to the heart. The heart is usually stopped and chilled, and the patient is kept alive by a heart-and-lung machine. Usually strips of blood vessels are removed from 1 or both of the patient's own legs (e.g., the great saphenous veins) to be used as bypass grafts . Other blood vessels can be used instead of leg veins, such as those inside your chest (internal mammary artery) or your arms (radial arteries).

The great advantage of angioplasty is that the artery is returned to normal size without resorting to major surgery. The drawback to angioplasty is restenosis. This is when the artery re-narrows due to scar formation and possibly further plaque formation. The risk of a blood vessel experiencing restenosis is highest within the first 3 to 6 months after the procedure , and is far more likely after angioplasty than after a CABG.

On the other hand, angioplasty allows people to come back for more treatment. If an artery re-narrows after CABG, there may not be enough vein or artery segments elsewhere in the body to perform a second graft. Moreover, a second angioplasty is far less traumatic to the body than a second open heart procedure.

Sometimes, circumstances will make the choice for you. People with many severe blockages, multiple coronary blockages, or those who have diabetes may be better off with CABG. Also, most hospitals don't perform angioplasty if there are several major arteries blocked. This is because angioplasty temporarily blocks the artery completely when the balloon is inflated. If the other arteries are also blocked, this could trigger a heart attack. However, if you're over 80 years of age or have other serious medical problems, you may be considered too vulnerable for the trauma of open-heart surgery. In that case, angioplasty may be a more attractive option, no matter how many arteries are blocked.

Possible complications

In most cases, angioplasty is safer than bypass surgery. Less than 1% of people die from complications of angioplasty. Non-fatal serious complications occur in around 5% of people who undergo this procedure . These complications include:

• tearing of the lining of the artery resulting in total blockage and possible heart attack – this can usually be repaired with a stent

• stroke from a clot that is dislodged while the catheter is inside the body

• bleeding or bruising

• kidney problems, especially in people with underlying kidney disease and diabetes – this is caused by the iodine contrast dye used for the X-ray; intravenous fluids and medications can be given before and after the procedure to try to reduce this risk