Angioplasty for coronary artery disease

Treatment Overview

Angioplasty and related techniques are known as percutaneous coronary intervention (PCI). Angioplasty is a procedure in which a narrowed section of the coronary artery is widened. Angioplasty is less invasive and has a shorter recovery time than bypass surgery, which is also done to increase blood flow to the heart muscle but requires open-heart surgery. Most of the time stents are placed during angioplasty.

An angioplasty is done using a thin, soft tube called a catheter. A doctor inserts the catheter into a blood vessel in the groin or above the elbow. The doctor carefully guides the catheter through blood vessels until it reaches the blocked portion of the coronary artery.

Cardiac catheterization, also called coronary angiography, is performed first to identify any blockages.

View the slideshow on angioplasty for coronary artery disease to see how an angioplasty is done.

Stents

A small, expandable wire tube called a stent is often permanently inserted into the artery during angioplasty. A very thin guide wire is inside the catheter. The guide wire is used to move a balloon and the stent into the coronary artery. A balloon is placed inside the stent and inflated, which opens the stent and pushes it into place against the artery wall. The balloon is then deflated and removed, leaving the stent in place. Balloon angioplasty is the most common method of inserting stents, although sometimes stents are placed without the use of a balloon. Because the stent is meshlike, the cells lining the blood vessel grow through and around the stent to help secure it.

Stenting should:

• Open up the artery and press the plaque against the artery 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.

Reclosure (restenosis) of the artery is much less likely to occur after stenting than with angioplasty alone. Stent placement is standard during most angioplasty procedures.

Drug-eluting stents are coated with medicines that prevent the growth of cells around the stent and thus are more effective than conventional stents in keeping the artery open. But experts do not yet know how safe the drug-eluting stents are over the long term or how well they work over the long term.

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 and the catheter insertion site checked for bleeding. You will have a large bandage or a compression device on your groin at the catheter insertion site to prevent bleeding. You will be instructed to keep your leg straight if the insertion site is near your groin area.

You can mostly likely 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.

You will take antiplatelet medicines to help prevent another heart attack or a stroke. If you get a stent, you will probably take aspirin 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 aspirin 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 with or without stenting is usually done if you have:

• Frequent or severe chest pain (angina) that is not responding to medicine.
• Evidence of severely reduced blood flow (ischemia) to an area of heart muscle caused by one narrowed coronary artery.
• An artery that is likely to be treated successfully with angioplasty whether or not stenting is also used.
• You are in good enough health to undergo 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 of complications or dying during angioplasty due to other health problems.
• The anatomy of the artery makes angioplasty or stenting too risky or will interfere with the success of the procedure.
• The surgeon or hospital does not perform enough procedures to ensure competency.
• 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 restenosis occurs, another angioplasty or bypass surgery may be needed.

Long-term outcomes of angioplasty on single-vessel disease are similar to those of coronary artery bypass surgery.¹

Angioplasty is considered very effective for reestablishing blood flow during a heart attack.¹ Angioplasty is at least as effective as (and possibly superior to) thrombolytics in the treatment of heart attack in medical centers where many procedures are performed.²

Bypass surgery may yield greater benefits than angioplasty for people with diabetes or those with extensive coronary atherosclerosis.¹ Additionally, bypass surgery may be the best option when there are blockages in the coronary arteries that cannot be reached during angioplasty or if angioplasty is tried but did not sufficiently widen the blood vessel, or when heart valve disease is present.

Stents are commonly used during angioplasty and other revascularization procedures. An artery is less likely to narrow again after angioplasty with stenting compared to angioplasty without stenting.³ Angioplasty with stenting, followed by aspirin and antiplatelet medicines, may lower the risk of a heart attack or a stroke for some people.

• Drug-eluting stents help prevent restenosis after angioplasty and stenting. These stents are coated with a medicine that prevents the growth of new tissue that often causes the treated artery to close up again. These stents almost completely prevent restenosis and may replace bare-metal stents in the future.⁴ But experts do not yet know how safe the drug-eluting stents are over the long term or how well they work over the long term.
• Rotational atherectomy. During an atherectomy, a thin flexible tube (catheter) is inserted through an artery in the groin or arm and carefully guided into the coronary artery that is narrowed. When the tube reaches the narrowed portion of the artery, a whirling blade (rotational atherectomy) is used to remove the fat and calcium buildup from the artery wall. For more information, see Atherectomy for coronary artery disease.

Risks

Risks of angioplasty may include:

• Bleeding at the puncture site.
• Damage to the blood vessel at the puncture site.
• Sudden closure of the coronary artery.
• Small tear in the inner lining of the artery.
• Heart attack.
• Need for additional procedures. Angioplasty may increase the risk of needing urgent bypass surgery. In addition, the repaired artery can renarrow (restenosis) and a repeat angioplasty may need to be performed.
• Reclosure of the dilated blood vessel (restenosis).
• Death. The risk of death is higher when more than one artery is involved.

What To Think About

Angioplasty does not require open-chest surgery and has less risk of immediate complications than bypass surgery. Evidence suggests that the long-term outcomes of bypass surgery and angioplasty are similar.⁵

Coronary artery bypass surgery may be a better option than angioplasty for people who have a diseased left main coronary artery, have diabetes, or have more than one diseased coronary artery. But aggressive treatment with certain medicines may also be effective for people with diabetes.

The benefits of angioplasty are much greater for a smoker if he or she quits smoking. A smoker's quality of life after angioplasty usually improves significantly after the procedure only if the smoking stops.⁶

For further discussion, see bypass surgery versus angioplasty.

Complete the special treatment information form (PDF) (What is a PDF document?) to help you understand this treatment.

References

Citations

1. Smith SC Jr, et al. (2006). ACC/AHA/SCAI 2005 guidelines update for percutaneous coronary intervention: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation, 113(1): 156-175.

2. Danchin N, Durand E (2006). Acute myocardial infarction, search date August 2004. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

3. Suwaidi JA, et al. (2000). Coronary artery stents. JAMA, 284(14): 1828-1836.

4. Morice M (2002). A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. New England Journal of Medicine, 346(23): 1773-1780.

5. Writing Group for the Bypass Angioplasty Revascularization Investigation (BARI) Investigators (2000). Five-year clinical and functional outcome comparing bypass surgery and angioplasty in patients with multivessel coronary disease. Journal of the American College of Cardiology, 35(5): 1122-1129.

6. Taira DA, et al. (2000). Impact of smoking on health-related quality of life after percutaneous coronary revascularization. Circulation, 102(12): 1369-1374.

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