|"Angioplasty 101" is
a overview for patients. You may click on any
underlined phrase in this section to see more detail or explanation.
For more information about
the disease process itself, its management or other treatments,
visit our PatientCenter.
Coronary angioplasty, sometimes called PTCA or PCI ,
is a catheter-based procedure performed by an interventional
cardiologist in order to open up a blocked
coronary artery and
restore blood flow to the heart muscle. Angioplasty now
is used as an alternative treatment to coronary artery
surgery (CABG) well more than half the time. It is less
invasive, less expensive,
and faster to perform, with the patient usually returning
home the next day. In most cases, following balloon angioplasty,
a stent will also be placed to keep the artery open. Angioplasty
is performed on an elective
basis to treat coronary artery disease, but is also
performed on an emergency
basis to treat a heart attack.
Testing and Diagnosis
In a non-emergency situation, the patient typically has sought
medical attention for symptoms such as angina.
A medical history is taken, assessment of risk factors
is made, and
a number of non-invasive tests are performed. For a full
explanation of tests used to diagnose coronary artery disease,
see the section "Patient
Guide to Heart Tests". If tests indicate a high
likelihood of obstructive coronary disease, then a cardiac
catheterization is scheduled. The patient
should inform the doctor or nurse of any known allergies
to the dye used in this procedure.
If the "cath" clearly reveals the coronary blockage,
this diagnostic test, also called an angiogram, is usually
transformed on the spot into the actual angioplasty treatment,
adding 30 minutes to the procedure (longer in complex cases).
Since all of the steps and hospitalization involved in a catheterization
are also necessary for performing an angioplasty, performing
both in the same session saves having to go through the entire
process again on a different day.
.The patient and cardiologist
or nurse educator should discuss this option (catheterization
with possible angioplasty, or "cath possible")
when scheduling the initial catheterization. In the majority
of cases, if an angioplasty is performed, a stent will be
implanted as well, to keep the artery open, so the patient
and cardiologist should also discuss the pros and cons of
metal and drug-eluting stents before a "cath possible" procedure,
especially any allergic reactions to required medications
like clopidogrel (Plavix) or aspirin.
The Catheterization Lab
Although the exact protocol varies among hospitals, the patient
usually checks in on the day of the catheterization, or
the night before. During an initial waiting period, the
patient is given some standard tests, signs release forms
for the hospital, and may talk to a nurse or cardiologist
about the procedure and what to expect. The patient then
is put on a gurney, brought to the area outside of the
catheterization laboratory ("cath lab") -- a
special room that is outfitted with high-resolution fluoroscopic
(X-ray) equipment. The patient usually stays in an anteroom
where some additional prepping is done. The patient's relatives
or support people can usually stay in a waiting room near
the cath lab. When it is time for the procedure, the patient
is brought into the cath lab itself and transferred to
the special table that is part of the fluoroscopy system.
In the cath lab there is a team
of medical personnel, there to assist the cardiologist
and to make sure the patient is
comfortable. During the procedure, which is a kind of "photo
session", the patient remains awake and conscious, in
order to respond to various instructions from the cardiologist
("take a deep breath", "hold your breath", "cough",
etc.). A nurse is available to administer light sedation
and pain relief intravenously, as needed, so the patient
should communicate his or her needs to the nurse. Should
the patient experience discomfort or anxiety, he or she can
let the medical staff know.
A sterile drape is placed over the patient and electrodes
to measure heart rhythms are placed on the patients chest.
The patient will also be put on an intravenous line (IV)
which involves a small needle stick in the arm. The IV
is used to administer various medications that may be required
during the procedure.
A local anesthetic is injected into
the patient's groin, arm or
the area is numbed, the introducer needle puncture is
made. The cardiologist threads a very thin soft-tipped guide
wire and catheter through the entry site and, while watching
on the fluoroscopic video screen, follows the main artery
in the body, called the aorta, up and around into the
of the left, or right coronary artery. The patient may
feel some discomfort when the needle is first inserted,
but should not feel anything during the wire/catheter placement.
Through the hollow catheter, the cardiologist
injects a small amount of dye, called contrast, which, when
viewed in motion under X-rays, reveals any obstructions or
plaques located within the coronary vessels. When the dye
is injected, the patient may feel a warm sensation. Views
from several angles for both the left and right coronary
arteries are recorded. Pictures are also taken as dye is
injected into the left ventricle to assess how well the heart
muscle is functioning.
From Diagnosis to Intervention
Depending on the number, severity and location of any blockages,
the cardiologist will probably do one of four things:
- No blockage -- the patient is negative
for coronary artery disease and will be referred back to
- Small blockage -- not severe enough to warrant an intervention
-- the patient will be referred for medical therapy
to relieve symptoms;
- Multiple blocked arteries with diffuse disease --
the cardiologist may recommend bypass surgery, which
suited for this
- One or more blocked but accessible
arteries - if the blockages can be reached, the cardiologist
as an angioplasty
The cardiologist makes some quick equipment changes and threads
a thin wire across the area of the blockage. A "rail" or
track into the coronary artery has now been established
and any number of therapeutic devices can be passed safely
and quickly over the wire and positioned precisely at the
obstruction. The initial device is usually a tiny balloon which is inflated one or more times. As the blockage is
opened, blood flow in the artery is stopped for very brief
periods, during which the patient may experience some chest
pain. This is normal. When the inflations are done, the
balloon is withdrawn.
In most interventions today,
a stent is
also used, usually following a balloon angioplasty. Unlike
balloon, the stent is expanded but remains in place, serving
as a permanent scaffolding for the newly widened artery.
In the U.S. most stents used are drug-eluting stents (a.k.a.
drug coated stents or "medicated" stents). These
devices dispense a small amount of medication over time (currently
paclitaxel or sirolimus) to prevent the growth of scar tissue
of the area. Drug-eluting stents have reduced the incidence
of restenosis (reclogging) from 20-30% to single digits.
One consideration in the use
of drug-eluting stents is that they require an extended
period of antiplatelet therapy after the procedure, usually
of aspirin and clopidogrel (Plavix) usually for at least
a year. Many physicians recommend continuing Plavix for life.
more on this issue see: "Late
Stent Thrombosis".) Early
cessation of these drugs can result in "stent
at the site of the stent -- this is a very serious complication
that is small in percentage but is fatal in almost one-third
of the incidents. If possible the patient should make sure
(1) are not allergic
Plavix or aspirin, and (2) will be able to comply with
the drug regimen, financially and otherwise.
and stents are the major devices utilized in catheter-based
devices that also may be used in specific situations,
such as intravascular
ultrasound or atherectomy catheters.
When the procedure is over, all equipment
is removed and the puncture site is compressed in order
to stop the bleeding. The patient
is moved to a recovery area, sometimes in the Coronary Care
Unit (CCU). For many patients, this period is the most
uncomfortable part because it is necessary to lie completely
still for 4-12 hours during the puncture site compression.
To avoid this, several types of vascular closure devices,
have been developed and are now being utilized to reduce
this period significantly. The patient should ask the cardiologist
if a "seal" will be used and discuss the pros and cons of
The compression (or sealing) and recovery procedures are
an angioplasty, stent or just a catheterization. Following
the procedure, the patient usually remains in the hospital
overnight, sometimes longer.
The cardiologist will prescribe certain medications to be
taken for a given period of time after the angioplasty.
For a short period, the patient should avoid lifting and
other activities that might reopen the puncture site wound.
The patient should also drink fluids to flush the dye out
of the system. The patient should immediately
contact the cardiologist if
after the angioplasty. It is normal for the puncture site
to be tender and bruised, however, any sign of a purplish
hematoma (considered a minor complication) or
should be reported to the patient's
The first six-month period is the most
important because it is usually during this period that
restenosis will occur, if it's going to occur at all. It
is also vital that patients adhere to any medications prescribed.
Often patients are prescribed low-dose aspirin
for life -- aspirin has antiplatelet properties which help
keep the blood cells from "sticking" together and
causing repeat blockages. In addition to aspirin, drug-eluting
recipients are also
clopidogrel (Plavix). Patients
need to comply with this regimen and not stop without
consulting their physician. It is therefore important
well as whatever
risk factors for coronary artery disease.
last updated: September 14, 2006