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12. Surgery - Angioplasty

 angioplasty

I have been told that I need an angioplasty. What is this?

Percutaneous transluminal coronary angioplasty (PTCA) is a method of using a balloon to squash or push the arterial narrowings out of the way. (The medical word for these narrowings is stenosis, pronounced ‘sten-oh-siss’.) PTCA is often shortened to ‘angioplasty’.

Because stents are used in nearly all cases (see later) we often call this percutaneous coronary intervention (PCI).

It is performed in the catheter laboratory usually by the same team who does the angiograms so you may meet some familiar faces. The doctor doing the operation will be the cardiologist, with whom you may already have had a consultation.

After a local anaesthetic, a thin tube (the catheter) is inserted into your artery at the top of your leg, or occasionally in an artery in your arm either at the elbow (brachial artery) or, more frequently, the wrist (radial artery). The catheter is guided under X-ray control to the heart, up the main artery known as the aorta. You cannot feel the tube moving. It is then directed into the coronary artery that contains the narrowing.

This catheter is called the guide catheter. A very fine wire (the guidewire) is now passed up through this catheter and into the coronary artery where it is steered past the narrowing. This may be a bit fiddly. Once it is across the narrowing, the balloon catheter is passed along the wire (like a monorail) and, following the wire, it slides across the narrowing. The balloon is blown up (inflated) once it is in position. This may cause some chest pain – let the doctor know if you have any pain at all.

The pressure in the balloon is increased and the narrowed part is pushed back into the wall of the artery where it has come from. The result is checked after the balloon has been deflated and removed back into the guide catheter. At this point the wire is still in place so that the balloon can be used again, or exchanged for a bigger balloon, if the result needs to be improved.

Once the doctor is satisfied with the result, the balloon and wire are removed; and you will be given a dye injection which checks how well the operation has gone; the guide catheter is then removed.

A small insertion sheath is left in the groin for about four hours, because the effects of blood thinning medication (heparin), used to prevent clotting on the wire or balloon, need to wear off.

The sheath is removed on the ward and the groin pressed firmly for 20 minutes or so. If the radial artery (at the wrist) is used, it is firmly bandaged.

A pressure device may be used which is slowly deflated. Often, the leg artery is plugged so that you can get up and about more quickly.

I am rather worried about the PTCA procedure. Will I be given any relaxing medicine beforehand?

This depends on you and how you are feeling. If you are anxious, then an injection of diazepam (Diazemuls or Valium) or mida - zolam helps you to relax.

Will I feel any pain when I undergo PTCA?

 

The local anaesthetic stings rather like when you have an angiogram. When the balloon is inflated, it blocks the artery temporarily (usually for 30 seconds or so), so you may get some chest pain. Let the doctor know if you are feeling any pain.

 How long does the PTCA procedure last? Will I need to be in hospital for long?

 Some procedures are quick (5–10 minutes), others take up to 1 hour. It depends on the number of narrowings in your particular case, whether they can be reached easily and whether you need a stent or not.

Usually you will be in hospital for one night. This is the big advantage over bypass surgery – you don’t have to spend long in hospital and you recuperate rapidly.

 How long will the effects of PTCA last?

 In 7 cases out of 10, PTCA gives a complete cure. However, for reasons we don’t understand fully, 30% of the narrowings come back in about 4–6 months. You will only know that the operation has not been entirely successful because your angina will return.

 If my angina returns, can the PTCA be repeated?

 Yes – up to five or six times, and each time it is performed, you have a 7 out of 10 chance of it remaining successful.

If you have no angina after 6 months, the effects will last for years, so the first 6 months constitute an important hurdle to overcome.

 Can the cardiologist perform PTCA on more than one narrowing at a time?

 Yes, as many as are necessary. Sometimes the procedure may be staged so that you come back for other narrowings to be done on a separate occasion. This decision depends on the importance of each narrowing and whether the procedure was an emergency or not – in an emergency only the most dangerous narrowing is done (the culprit), and the rest are completed when matters have settled down.

 I am worried that things may go wrong when I have my PTCA. Is this likely?

 Things are very unlikely to go wrong but, if they do not work out, there are other ways to sort out the problem. Complications are not common but they do occur. Sometimes the artery tears and closes completely. We can correct this by inserting a stent or moving on to bypass surgery. However, angioplasty is successful over 95% of the time. You will be asked to sign a form giving your consent to having a stent inserted or bypass surgery, just in case the PTCA is not successful.

 I have been told that I am not suitable for PTCA. Why is this?

Some people have complicated narrowings and complete blockages which unfortunately are not suitable for PTCA. If you suffer from angina and many arteries are affected, a coronary bypass may be the best option for you.

When my husband went into hospital for a PTCA, he had to sign a form saying he consented to having a stent inserted if it was found necessary during the operation. What is a stent and how does it work?

Astent is a metal mesh cage rather like a small meshwork tube. It is made of thin flexible metal wire, and is fixed to a balloon with the balloon deflated.

The original angioplasty balloon is removed – the wire is still in the artery so we have access to the narrowing - and the balloon with the stent on it is passed along the wire to the narrowing.

The balloon inside the stent is inflated and the stent expands to the size of the balloon. It embeds itself into the artery wall and holds the artery open mechanically.

The balloon is deflated and removed but the stent is permanently left behind. More than one stent may be used and the stent sizes vary according to the size of the arteries. Stents may be inserted without a prior balloon - this is known as direct stenting.

When will the cardiologist decide to insert a stent?

There are various reasons why the cardiologist decides to use a stent. The commonest are:

• If the angioplasty is not successful or the artery closes off;

• It is the cardiologist’s choice (the most common reason);

• If the narrowing comes back 4-6 months after angioplasty;

• If the artery is large and the narrowing short, as the recurrence rate with a stent is reduced to 10–15%;

• If the narrowing is within a vein used for coronary bypass.

Stents are now used in over 90% of cases because of the better longterm results, with only 15% getting a narrowing within the stent after 6 months (this figure rises to 30% with the balloon on its own). If possible, they are placed directly without using a balloon beforehand as this reduces the risk of a complication.

Drug-eluting stents have been developed and are widely used because they have better than 95% long-term success. These have a drug coated on the metal stent, which acts to stop any further narrowing occurring. They are much more expensive than ordinary stents, which are now known as bare metal stents, but obviously reduce the chances of a repeat procedure. They may be particularly important in people with a higher risk of recurrence - those who have had a recurrence already, people with diabetes, and when the artery being stented is small.

I need an MRI scan. Do I tell the radiologist about my stents?

Yes. Routine MRI scanning is safe in all patients who have had a stent in place for 6 weeks. Stainless steel stents may displace in the first 6 weeks, but other makes remain secure. The chances of a stainless steel stent moving are minimal, however, so that MRI in an emergency should go ahead. Non-urgent cases should play safe and wait 6 weeks.

I was not offered a stent as a choice. Why was this?

This is most likely because angioplasty alone gave an excellent result. Stents are not as successful in smaller arteries, so this may have been the reason. Sometimes the arteries are too tortuous to allow a stent to pass through.

I am on tablets only at the moment for my angina. Is angioplasty or stenting better than medications?

Angioplasty or stenting can relieve any pain that medications have failed to control. They do not, however, provide any benefits compared to medication for preventing heart attacks. They are used only if conventional medical treatment does not give you relief from pain and a good quality of life. Angioplasty is a safe and effective procedure, but any operation has a slight risk, which you should avoid if possible.

I have been told that I need an angioplasty. I would prefer not to have an operation. Am I being overcautious?

 Probably not. Because a narrowing looks suitable for a balloon, that doesn’t mean that it is the best treatment. Angina from a narrowing in a branch vessel that is not a danger to life will usually settle with drug treatment, and the angioplasty option can be saved for later. As angioplasty in research studies has not been shown to improve (or shorten) life expectancy, it must be used selectively and it is then a very effective procedure. Using any procedure in every circumstance invites complications and devalues what is a useful form of therapy.

 I am worried about having angioplasty done. Is there any chance that I will not get through the operation?

You have a greater than 99% chance of survival. These statistics include emergency operations and very sick people – routine cases like yours have a lower risk.

When will the doctor decide that I should have an angioplasty?

If you have angina and your tablets are not controlling it, the doctor will probably refer you for an angioplasty, if the narrowings are suitable. You will have an 80–90% chance of being relieved of your angina as a result.

 I have just undergone an angioplasty with a stent and now been given some medication called clopidogrel. What is this drug for?

This is a powerful aspirin-like drug that prevents clotting on stents until they fully bed in. You usually start taking it about 6 hours before the procedure with a ‘loading dose’ of 300–600mg. You will then take at least 75 mg daily for 4 weeks with a bare metal stent.

Most doctors use it with aspirin also.

Clopidogrel 75 mg daily is also used as an alternative in those unable to tolerate aspirin. Clopidogrel is also used in patients with unstable angina as it reduces the complication rate. Skin rashes are the commonest side effect, and you may also notice that you bruise easily.

I have a drug-eluting stent in place and have been told to take clopidogrel and aspirin together for a year – is that correct?

Drug-eluting stents are vulnerable to clotting just like bare metal stents but they also have a late clotting risk when clopidogrel is stopped. Though this is not common it can be serious so doctors advise clopidogrel and aspirin for at least a year, and for some people, indefinitely.

Clopidogrel has to be stopped for at least 5 days if you need an operation, such as a hernia repair, to avoid bleeding. A drugeluting stent may therefore not be used if you plan to have non-heart surgery soon after the procedure.

Now that I have had an angioplasty, which has cured me of my angina pain, can I throw away all those tablets?

No, not all! You will need to continue with aspirin, cholesterollowering tablets and blood pressure tablets, if necessary. Any tablets that you take for angina might be reduced or stopped. Ask your doctor first – do not stop any medication without advice.

 My wife has just come out of hospital where she under went an angioplasty. She wasn’t allowed to drive herself home. Why?

Aweek off is recommended. If you are recovering satisfactorily, you can then start driving again. The competent government department in some countries need to be notified but car insurance companies must be informed.

I hold a licence and drive a lorry for a living. Will I lose my job and livelihood after angioplasty?

Driving is not recommended anyway if you have angina, even if your symptoms are controlled on medical treatment. This is a safety rule to protect the general public in case you should lose control of the vehicle during an attack. If you have heart failure, the competent government department can refuse you a licence.

After a heart attack, bypass or angioplasty, you should stop professional driving for 6 weeks and you will only be allowed to resume if you have no symptoms and are able to complete an exercise test to the required standard.

How many people who have undergone angioplasties or stent insertion will have to then have an urgent bypass operation?

Only about 1 in 100.

My doctor mentioned a PCI – what is this?

PCI stands for percutaneous coronary intervention and this term covers both balloons and stents.

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