Angioplasty

There is a lot of advancement in the treatment options for coronary heart disease, which saves many lives, such as Percutaneous Coronary Intervention (PCI), also known as Angioplasty.

Angioplasty is a non-surgical procedure, which is used to open the blocked coronary arteries. It can be done with or without a stent. When the stents were not developed, at that time, balloon angioplasty was the only treatment option. But nowadays, as the coronary stents are developed, they are used with recent technological advances.

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When the coronary arteries are blocked or narrowed with the fatty material (known as atheroma), your surgeon will perform angioplasty to open up those arteries and restore blood supply to the heart muscles. This is done to prevent damage to the heart muscles, which can lead to decreased pumping efficiency of your heart. Besides, it will also relieve you from symptoms, such as chest pain, which can occur due to obstruction of the blood flow, and shortness of breath. Angioplasty may also be advised after a heart attack.

Angioplasty is the treatment of choice when you have any one of the following coronary artery diseases, which can lead to a heart attack (when a part of the heart muscle does not receive adequate blood and it leads to their damage):

• Unstable angina
  When chest pain becomes severe and remains for a long duration, it is known as unstable angina. It does not get relieved even after taking rest. 
• NSTEMI (Non-ST Elevation Myocardial Infarction)
  It is the most common type of heart attack, which is diagnosed based on the findings of ECG, elevated levels of certain enzymes or markers, which indicate heart damage.
• STEMI (ST Elevation Myocardial Infarction)
  It is a more serious type of heart attack than NSTEMI in which besides heaviness or pain in the centre of the chest, constant tiredness is the most common complaint.
• Coronary artery perforation
  Coronary artery perforation is when the blood vessel punctures due to any cause, such as during angioplasty procedure.

If you have any one of the above-mentioned coronary heart diseases or any symptoms related to heart diseases, such as chest pain, difficulty in breathing and lightheadedness, then it may suggest a blockage in your coronary arteries. So, your doctor may decide the coronary artery bypass surgery or angioplasty based on the extent of blockage and your overall medical condition.

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Before the procedure, your doctor will advise some routine tests such as:

• Complete blood count test to ensure you have all the blood components within the normal range.
• Liver function test to check the levels of liver enzymes and its function.
• Kidney function test to ensure there are no abnormalities with their function and the levels of hormones released by them.
• Chest X-ray.
• ECG (Electrocardiography) to assess heart activity.
• CPET (Cardiopulmonary Exercise Testing) to measure the amount of oxygen used and carbon dioxide produced by the body.
• Echocardiogram, which is also known as Cardiac echo (sonogram of the heart) is also done to check the condition of the heart tissues.

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After receiving a handful of professional advice, you can make your mind to go for this procedure i.e. angioplasty. This procedure is done by a cardiologist (a doctor who specialises in the treatment of heart-related diseases) in the hospital’s cardiac catheterisation laboratory (also known as a hospital cath lab). The team of a cath lab includes a cardiologist, general physician, cath lab nurses, technicians, radiographers, ward nurses and junior resident doctor. Following are the steps of the procedure:

• Before the procedure, your doctor will take the consent form signed by you.  You will receive some pain-numbing medication through intravenous (IV) line in your arm, medicines to relax your body and blood-thinning medicines to prevent blood clotting during the procedure.
• You will stay awake during the whole procedure. Your doctor will give you local anaesthesia (an agent to numb the surgical area of the body) from where the catheter is inserted inside the coronary artery.
• The thigh area or wrist area is shaved (wherever required) and cleaned. A cut is made and the artery is punctured to obtain access to it with the help of a technique known as the Seldinger technique. In this technique, a sharp hollow needle is used to puncture the blood vessel and a blunt, round-tipped wire is inserted through the needle into the blood vessel. After that, the needle is taken out and a sheath or blunt cannula (plastic tube) is inserted such that it covers the guidewire. Once the sheath is in place, the guidewire is withdrawn.
• The sheath is left behind in the blood vessel to hold the opening of the artery and to avoid any injury. A dye is also used to visualise the site of obstruction. Your doctor may also use X-rays to carefully check the position of the catheter or guidewire. 

There are two main approaches to catheterisation, which is a procedure to examine the structure and function of the heart. A catheter or hollow plastic tube is inserted into a large blood vessel leading to the heart.

• Transfemoral or classical approach
• Transradial approach
• Transbrachial approach (not routinely done)

Transfemoral approach

This procedure is more classical than the others and permits easy access to the heart in which the catheter will be inserted in the femoral artery (an artery in your groin area which is the main branch that supplies blood to the leg).

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Transradial approach

In this approach, the radial artery (artery of the forearm which is close to the surface and supplies the hand and arm) is punctured to insert the catheter inside the blood vessel. It is an easily accessible site with a lesser risk of nerve or adjacent tissue damage but takes more time as compared to the transfemoral approach. The transradial approach is relatively inexpensive and you may get discharged early from the hospital.

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Balloon Angioplasty

It is used to widen the blocked or obstructed arteries with the help of a balloon catheter. In this procedure, a balloon is attached to the tip of a catheter, which is inserted inside the coronary artery through the entry site from the wrist or groin area. After reaching the artery, the balloon is inflated which will compress the fatty material against the inner wall of the artery and ultimately, will help in restoring the normal blood flow to the heart. After deflating, the balloon will be withdrawn from the artery through the entry site. In this procedure, stents are not used and it is known as angioplasty without stents.

There are some major drawbacks of this procedure, such as:

• Obstruction of the vessel.
• Coronary artery dissection in which tearing occurs in one of the blood vessels of the heart.
• A blood clot is formed inside the blood vessel causing obstruction of the blood flow, which is known as acute arterial thrombosis.
• Narrowing of the blood vessels can occur again due to redeposition of the fatty material. This is known as restenosis, which leads to reduced blood flow in the blood vessel.

To cope with these major drawbacks, coronary stents are introduced in angioplasty procedures, which is known as Angioplasty with stents.

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What is a coronary stent?

When coronary arteries are blocked due to atherosclerosis (blockage of arteries due to fatty material deposition), which leads to reduced blood flow to the brain or other organs, chest pain and muscle weakness. Coronary stents are used to treat atherosclerosis. These stents are small tube-like, expandable devices, which are placed in the arteries to keep them open and maintain the regular blood flow to the heart.

The choice for the stents is also based upon your tolerance to the medicines, which are used to minimise the bleeding.

After the procedure is done, your doctor may remove the catheter and then put a bandage on the entry site. After catheterisation, you may notice some bruises, soreness, bleeding or some discomfort at the site where the catheter was inserted. As it is a short procedure, you will recover in a couple of hours and may be discharged from the hospital on the same day.

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After the procedure is done, your doctor may remove the catheter and then put a bandage on the entry site. After catheterisation, you may notice some bruises, soreness, bleeding or some discomfort at the site where the catheter was inserted. As it is a short procedure, you will recover in a couple of hours and may be discharged from the hospital on the same day.

After angioplasty, you will get instructions from your doctor regarding the medicines you have to take, especially if stents are placed, anti-clotting medicines will be prescribed. You need to take them exactly as prescribed, especially for at least three to 12 months, so as to avoid any serious complications in the near future.

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Some complications may occur after your surgery. These are as follows:

• Bleeding at the opening site may occur from where the catheter was inserted in the coronary artery.
• Blood vessel damage.
• Allergic reaction to the contrast dye.
• Arrhythmia may occur in which the heart beats irregularly, either too fast or too slow.
• Kidney damage.
• Heart attack.
• Stroke may occur due to poor blood flow to the brain, which leads to cell death.
• Blood clots may also develop if blood-thinning medicines are not given before the procedure.
• Chest pain may occur during the procedure when the balloon is being inserted, which temporarily blocks the blood supply to the heart.
• Coronary artery perforation is a rare but very serious complication, which mostly occurs during the angioplasty procedure in which the blood vessel gets punctured. It can be due to an over inflation of the balloon, during catheterisation or while insertion of the wire in the blood vessel.
• After angioplasty, narrowing of the blood vessels occurs due to various reasons, which is known as In-stent restenosis.

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After one week of the surgery, it is recommended to visit the hospital to follow up with your general practitioner. The following things may be done during a follow up:

• General body checkup.
• Examination of the puncture site to check for any bleeding.
• Auscultation of the heart (listening to the sounds of the heart with a stethoscope).
• Measurement of blood pressure.
• Routine lab tests, such as complete blood count to check for anaemia, kidney function test and liver function test.
• ECG to check the normal functioning of the heart.
• Continuation of the medicines which were prescribed earlier.

“National Disease Management Guidelines”  recommend that after angioplasty procedure is done, you should follow up regularly after every three to six months with the general physician. You can plan some additional visits too if you notice something wrong with your general health.

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After the procedure is done, you may find the following changes in your life:

• Quality of life is improved.
• Frequency of chest pain is decreased.
• Daily performance is improved.
• Less risk of having a heart attack and heart failure.
• Overall, very low chances of succumbing to heart-related diseases.

After angioplasty is done, if you notice any symptoms similar to those that you had before angioplasty, such as shortness of breath or chest pain, don’t wait! Visit your doctor immediately without any delay or if your condition worsens, call emergency medical help.

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