Percutaneous Transluminal Coronary Angioplasty (PTCA) and Stent Placement
Percutaneous Coronary Intervention (PCI), Coronary Angioplasty, and Stent Placement
What is coronary angioplasty?
The use of fluoroscopy (a special type of X-ray, similar to an X-ray "movie") assists the doctor in the location of blockages in the coronary arteries as the contrast dye moves through the arteries.
A technique called intravascular ultrasound (IVUS), a technique that uses a computer and a transducer that sends out sound waves to create images of the blood vessels, may be used during PCI. The use of IVUS provides direct visualization and measurement of the inside of the blood vessels and may assist the doctor in selecting the appropriate size of balloons and/or stents, to ensure that a stent, if used, is properly opened, or to evaluate the use of other angioplasty instruments. A technique called fractional flow reserve (FFR) assessment is often used during a catheterization to assist in determining the significance of a moderate coronary narrowing. The technique involves placing a pressure-transducing wire across the narrowing, and after a brief infusion of medication, measuring the pressure change in the coronary artery. This may assist the doctor in deciding whether PCI or stenting is appropriate.
The doctor may determine that another type of procedure is necessary. This may include the use of atherectomy (removal of plaque) at the site of the narrowing of the artery. In atherectomy, there may be tiny blades on a balloon or a rotating tip at the end of the catheter. When the catheter reaches the narrowed spot in the artery, the plaque is broken up or cut away to open the artery.
What is stent placement?
Coronary stents are now almost universally used in PCI procedures, often following balloon angioplasty, which opens the narrowed artery and facilitates stent placement. A stent is a tiny, expandable metal coil that is inserted into the newly-opened area of the artery to help keep the artery from narrowing or closing again.
Once the stent has been placed, tissue will begin to form over it within a few days after the procedure. The stent will be completely covered by tissue within a month or so. It is necessary to take medications, such as aspirin, clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta), which decrease the "stickiness" of platelets (special blood cells that clump together to stop bleeding), in order to prevent blood clots from forming inside the stent. Your doctor will provide specific instructions regarding which medications need to be taken and for how long.
Newer stents (drug-eluting stents, or DES) are coated with medication to prevent the formation of scar tissue inside the stent. These drug-eluting stents release medication within the blood vessel itself. This medication inhibits the overgrowth of tissue that can occur within the stent. The effect of this medication is to deter the narrowing of the newly stented blood vessel. Because stents can become blocked, it is important for you to talk with your doctor about what you need to do if you experience chest pain after a stent placement.
If scar tissue does form inside the stent, a repeat procedure may be performed, either with balloon angioplasty or with a second stent, or occasionally with local radiation therapy (called brachytherapy) may be used to clear the scarred area and open up the vessel.
Other related procedures that may be used to assess the heart include resting or exercise electrocardiogram (ECG or EKG), Holter monitor, signal-averaged ECG, cardiac catheterization, chest X-ray, computed tomography (CT scan) of the chest, echocardiography, electrophysiological studies, magnetic resonance imaging (MRI) of the heart, myocardial perfusion scans, radionuclide angiography, and cardiac CT scan. Please see these procedures for additional information.
An additional technique is rotational atherectomy. This is sometimes used to aid stent placement when the plaque is hardened and calcified.
Coronary artery disease
Coronary artery disease (CAD) is the narrowing of the coronary arteries (the blood vessels that supply oxygen and nutrients to the heart muscle), caused by a buildup of fatty material within the walls of the arteries. This process causes the inside of the arteries to become narrowed, limiting the supply of oxygen-rich blood to the heart muscle.
To better understand how coronary artery disease affects the heart, a review of basic heart anatomy and function follows.
The heart is basically a pump. The heart is made up of specialized muscle tissue, called the myocardium. The heart's primary function is to pump blood throughout the body, so that the body's tissues can receive oxygen and nutrients.
Like any pump, the heart requires fuel in order to work. The myocardium requires oxygen and nutrients, just like any other tissue in the body. However, the blood that passes through the heart's chambers is only passing through on its trip to the rest of the body. This blood does not give oxygen and nutrients to the myocardium. The myocardium receives its oxygen and nutrients from the coronary arteries, which lie on the outside of the heart.
When the heart tissue does not receive an adequate blood supply, it cannot function as well as it should. If the myocardium's blood supply is decreased for a length of time, a condition called ischemia develops. Ischemia can decrease the heart's pumping ability, because the heart muscle becomes weakened due to a lack of nutrients and oxygen.
Unfortunately, you may not have any symptoms of early coronary artery disease, yet the disease may continue to progress until sufficient artery blockage occurs, leading to angina (chest pain or discomfort due to coronary artery disease). Symptoms of angina include chest or arm pain, chest pressure, fatigue, indigestion, palpitations, and shortness of breath.
If a coronary artery is completely closed by a blood clot, a myocardial infarction (heart attack) may occur. The blood clot may occur when a plaque (buildup of fatty tissue inside the artery walls) ruptures or tears, leading to abrupt accumulation of a blood clot at that site, blocking the blood vessel. If the blood flow cannot be restored quickly to the particular area of the heart muscle affected, the tissue dies.
Reasons for the procedure
PCI is performed to restore coronary artery blood flow when the narrowed artery is in a location that can be reached in this manner. Not all coronary artery disease can be treated with PCI. Your doctor will decide the best treatment of your CAD based on your individual circumstances.
There may be other reasons for your doctor to recommend a PCI.
Risks of the procedure
Possible risks associated with PCI, stenting, atherectomy, and related procedures, but are not limited to, the following:
Bleeding at the catheter insertion site (usually the groin, the wrist, or the arm)
Blood clot or damage to the blood vessel at the insertion site
Blood clot within the vessel treated by PCI or stent
Infection at the catheter insertion site
Cardiac dysrhythmias or arrhythmias (abnormal heart rhythms)
Chest pain or discomfort
Rupture of the coronary artery, requiring open-heart surgery
You may want to ask your doctor about the amount of radiation used during the procedure and the risks related to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such as previous scans and other types of X-rays, so that you can inform your doctor. Risks associated with radiation exposure may be related to the cumulative number of X-ray examinations and/or treatments over a long period of time.
If you are pregnant or suspect that you may be pregnant, you should notify your health care provider due to risk of injury to the fetus from a PCI. Radiation exposure during pregnancy may lead to birth defects. If you are lactating, or breastfeeding, you should notify your health care provider.
There is a risk for allergic reaction to the dye. Patients who are allergic to or sensitive to medications, contrast dye, or iodine should notify their doctor. Also, patients with kidney failure or other kidney problems should notify their doctor.
For some patients, having to lie still on the procedure table for the length of the procedure may cause some discomfort or pain.
There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.
Before the procedure:
Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
Notify your doctor if you have ever had a reaction to any contrast dye, or if you are allergic to iodine.
Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).
You will need to fast for a certain period of time prior to the procedure. Your doctor will notify you how long to fast, whether for a few hours or overnight.
If you are pregnant or suspect that you may be pregnant, you should notify your doctor.
Notify your doctor if you have any body piercings on your chest and/or abdomen.
Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant or antiplatelet (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop some of these medications prior to the procedure. However, for planned PCI procedures, your doctor will likely want you to continue taking aspirin and antiplatelet medications, so be sure to ask.
Your doctor may request a blood test prior to the procedure to determine how long it takes your blood to clot. Other blood tests may be done as well.
Notify your doctor if you have a pacemaker.
You may receive a sedative prior to the procedure to help you relax.
Based on your medical condition, your doctor may request other specific preparation.
During the procedure
A PCI may be performed as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor's practices.
Generally, a PCI follows this process:
You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear your dentures or hearing aid if you use either of these.
You will be asked to remove clothing and will be given a gown to wear.
You will be asked to empty your bladder prior to the procedure.
If there is excessive hair at the area of the catheter insertion (groin area), the hair may be clipped off.
An intravenous (IV) line will be started in your hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed.
You will be placed in a supine (on your back) position on the procedure table.
You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure.
There will be several monitor screens in the room, showing your vital signs, the images of the catheter being moved through the body into the heart, and the structures of the heart as the dye is injected.
You will receive a sedative medication in your IV before the procedure to help you relax. However, you will likely remain awake during the procedure.
Your pulses below the insertion site will be checked and marked so that the circulation to the limb below the site can be checked after the procedure.
A local anesthetic will be injected into the skin at the insertion site. You may feel some stinging at the site for a few seconds after the local anesthetic is injected.
Once the local anesthetic has taken effect, a sheath, or introducer, will be inserted into the blood vessel. This is a plastic tube through which the catheter will be inserted into the blood vessel and advanced into the heart. The sheath, or introducer, will be inserted into the blood vessel at either the groin or wrist. (The radial artery, or wrist approach, is now commonly used.)
The angioplasty catheter will be inserted through the sheath into the blood vessel. The doctor will advance the catheter through the aorta into the heart. Fluoroscopy will be used to assist in advancing the catheter to the heart.
The catheter will be advanced into the coronary arteries. Once the catheter is in place, contrast dye will be injected through the catheter into your coronary arteries in order to see the narrowed area(s). You may feel some effects when the contrast dye is injected into the IV line. These effects include a flushing sensation, a salty or metallic taste in the mouth, and/or a brief headache. These effects usually last for a few moments.
You should notify the doctor if you feel any breathing difficulties, sweating, numbness, itching, nausea and/or vomiting, chills, or heart palpitations.
After the contrast dye is injected, a series of rapid, sequential X-ray images of the heart and coronary arteries will be made. You may be instructed to take in a deep breath and hold it for a few seconds during this time.
When the doctor locates the narrowed artery, the catheter will be advanced to that location and the balloon will be inflated to open the artery. It is possible to experience some chest pain or discomfort at this point as a result of blood flow being temporarily blocked by the inflated balloon. Any chest discomfort or pain should go away when the balloon is deflated. However, if you notice any continued discomfort or pain, such as chest pain, neck or jaw pain, back pain, arm pain, shortness of breath, or breathing difficulty, tell your doctor immediately.
The doctor may inflate and deflate the balloon several times. The decision may be made at this point to insert a stent in order to maintain the artery's opening. In some cases, the stent may be inserted into the artery before the balloon is inflated. The inflation of the balloon will open the artery and fully expand the stent.
The doctor will take measurements, pictures, or angiograms after the artery has been opened. Once it has been determined that the artery is opened sufficiently, the angioplasty catheter will be removed.
The insertion site may be closed with a closure device that uses collagen to seal the opening in the artery, by the use of sutures, or by applying manual pressure over the area to keep the blood vessel from bleeding. Your doctor will determine which method is appropriate for your condition.
If a closure device is used, a sterile dressing will be applied to the site. If manual pressure is used, the doctor (or an assistant) will hold pressure on the insertion site so that a clot will form. Once the bleeding has stopped, a very tight bandage will be placed on the site. A small sandbag or other type of weight may be placed on top of the bandage for additional pressure on the site, especially if the site is in the groin.
Your doctor may decide not to remove the sheath, or introducer from the insertion site for approximately four to six hours, in order to allow the effects of blood-thinning medication given during the procedure to wear off. You will need to lie flat during this time. If you become uncomfortable in this position, your nurse may give you medication to make you more comfortable.
You will be assisted to slide from the table onto a stretcher so that you can be taken to the recovery area. NOTE: If the insertion was in the groin, you will not be allowed to bend your leg for several hours.
If the insertion site was in the arm, your arm will be kept elevated on pillows and kept straight by placing your arm in an arm guard (a plastic arm board designed to immobilize the elbow joint). In addition, a plastic band (works like a belt around the waist) may be secured around the arm near the insertion site. The band will be loosened at given intervals and then removed at the appropriate time determined by your doctor.
After the procedure
In the hospital
After the procedure, you may be taken to the recovery room for observation or returned to your hospital room. You will remain flat in bed for several hours after the procedure. A nurse will monitor your vital signs, the insertion site, and circulation/sensation in the affected leg or arm.
You should immediately inform your nurse if you feel any chest pain or tightness, or any other pain, as well as any feelings of warmth, bleeding, or pain at the insertion site in your leg or arm.
Bedrest may vary from two to six hours depending on your specific condition. If your doctor placed a closure device, your bedrest may be of shorter duration.
In some cases, the sheath or introducer may be left in the insertion site. If so, the period of bedrest will be prolonged until the sheath is removed. After the sheath is removed, you may be given a light meal.
You may feel the urge to urinate frequently because of the effects of the contrast dye and increased fluids. You will need to use a bedpan or urinal while on bedrest so that your affected leg or arm will not be bent.
After the specified period of bed rest has been completed, you may get out of bed. The nurse will assist you the first time you get up, and will check your blood pressure while you are lying in bed, sitting, and standing. You should move slowly when getting up from the bed to avoid any dizziness from the long period of bedrest.
You may be given pain medication for pain or discomfort related to the insertion site or having to lie flat and still for a prolonged period.
You will be encouraged to drink water and other fluids to help flush the contrast dye from your body.
You may resume your usual diet after the procedure, unless your doctor decides otherwise.
You will most likely spend the night in the hospital after your procedure. Depending on your condition and the results of your procedure, your stay may be longer. You will receive detailed instructions for your discharge and recovery period.
Once at home, you should monitor the insertion site for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the insertion site. A small bruise is normal. If you notice a constant or large amount of blood at the site that cannot be contained with a small dressing, notify your doctor.
If your doctor used a closure device for your insertion site, you will be given specific information regarding the type of closure device that was used and how to take care of the insertion site. There will be a small knot, or lump, under the skin, where the insertion site was. This is normal. The knot should gradually disappear over a few weeks.
It will be important to keep the insertion site clean and dry. Your doctor will give you specific bathing instructions.
You may be advised not to participate in any strenuous activities. Your doctor will instruct you about when you can return to work and resume normal activities.
Notify your doctor to report any of the following:
Fever and/or chills
Increased pain, redness, swelling, or bleeding or other drainage from the insertion site
Coolness, numbness and/or tingling, or other changes in the affected extremity
Chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness, and/or fainting
Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.
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