Treatments

Percutaneous Transluminal Coronary Angioplasty (PTCA)

Percutaneous coronary intervention (PCI) is performed to open blocked coronary arteries caused by coronary artery disease (CAD) and to restore arterial blood flow to the heart tissue without open-heart surgery.

Using a guide wire, a special catheter (long hollow tube) is inserted into the coronary artery and past the blockage in the blocked area. The catheter contains a tiny balloon. When the catheter is in place, the balloon is inflated. The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow. 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.

Hospital Stay: Hospital Stay: 4 days
Duration: Duration: 1-3 hrs
Cost Estimate: Cost Estimate: 4275 USD - 6000 USD These are indicative prices in Indian Hospitals

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. 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. 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, local radiation therapy (called brachytherapy) may be used to clear the scarred area and open up the vessel.

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.

Before the Procedure

  • The patient should notify the doctor if he/she has ever had a reaction to any contrast dye, or if allergic to iodine.
  • The patient should notify your doctor if he/she is sensitive to or allergic to any medications, latex, tape, and anaesthetic agents (local and general).
  • The patient will need to fast for a certain period of time prior to the procedure, usually overnight.
  • If the patient is pregnant or suspect that she may be pregnant, the doctor should be notified.
  • The doctor should be notified if the patient has any body piercings on the chest and/or abdomen.
  • The doctor should be notified about all medications (prescription and over-the-counter) and herbal supplements that the patient is taking.
  • The patient may be asked to withhold certain medications prior to the procedure. The doctor will provide detailed instructions.
  • The doctor should be notified if the patient has a history of bleeding disorders or if the patient is taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for the patient to stop some of these medications prior to the procedure.
  • The doctor may request a blood test prior to the procedure to determine how long it takes for the patient’s blood to clot. Other blood tests may be done as well.
  • The doctor should be notified if the patient has heart valve disease or if there is a pacemaker inserted.
  • Based on the medical condition of the patient, the doctor may request other specific preparation.

During the Procedure

A PCI / PTCA may be performed as part of the patient’s stay in the hospital or as a day care procedure. Generally, a PCI / PTCA follows this process:

  • The patient will be asked to remove any jewellery or other objects that may interfere with the procedure. The patient may wear dentures or hearing aids.
  • The patient will be asked to remove clothing and will be given a gown to wear.
  • The patient will be asked to empty his/her bladder prior to the procedure.
  • If there is excessive hair at the catheter insertion site (groin area), the hair may be clipped off.
  • An intravenous (IV) line will be started in the patient’s hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed.
  • The patient will be placed in a supine (on his/her back) position on the procedure table.
  • The patient 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. The patient’s 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 the patient’s 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.
  • The patient will receive a sedative medication in the IV before the procedure to help him/her relax. However, the patient will likely remain awake during the procedure.
  • The patient’s pulses below the catheter 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 anaesthetic will be injected into the skin at the insertion site. The patient may feel some stinging at the site for a few seconds after the local anaesthetic is injected.
  • Once the local anaesthetic 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. If the arm is used, a small incision (cut) may be made to expose the blood vessel for insertion of the sheath.
  • The angioplasty catheter will be advanced through the aorta to the left side of 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 the coronary arteries to visualize the narrowed areas. The patient may feel some effects when the contrast dye is injected into the IV line. These effects may include a flushing sensation, a salty or metallic taste in the mouth, and/or a brief headache. These effects usually last for only a few moments.
  • The patient should notify the doctor if he/she feels any breathing difficulties, sweating, numbness, nausea and/or vomiting, chills, itching, 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. The patient 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 there is continued discomfort or pain, such as chest pain, neck or jaw pain, back pain, arm pain, shortness of breath, or breathing difficulty, the patient should tell the 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, by using a clip to bind the artery together, or by applying manual pressure over the area to keep the blood vessel from bleeding. The doctor will determine which method is appropriate for the patient’s 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.
  • The 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. The patient will need to lie flat during this time. If he/she becomes uncomfortable in this position, the nurse may give medication to reduce the discomfort.
  • The patient will be assisted to slide from the table onto a stretcher so that he/she can be taken to the recovery area.
  • If the insertion was in the groin, the patient will not be allowed to bend the leg for several hours.
  • If the insertion site was in the arm, the arm will be kept elevated on pillows and kept straight by placing the 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 removed at the appropriate time as determined by the doctor.

After the Procedure

After the procedure, the patient may be taken to the recovery room for observation or returned to the hospital room. The patient will remain flat in bed for several hours after the procedure. A nurse will monitor the vital signs, the insertion site, and circulation/sensation in the affected leg or arm. The patient should immediately inform the nurse in case of any chest pain or tightness, or any other pain, as well as any feelings of warmth, bleeding, or pain at the insertion site. Bed rest may vary from two to six hours depending on the patient’s specific condition. If the physician has placed a closure device, bed rest may be of shorter duration. In some cases, the sheath or introducer may be left in the insertion site. If so, the period of bed rest will be prolonged until the sheath is removed. After the sheath is removed, the patient may be given a light meal.

The patient may feel the urge to urinate frequently because of the effects of the contrast dye and increased fluids. After the specified period of bed rest has been completed, the patient may get out of bed. The patient should move slowly when getting up from the bed to avoid any dizziness from the long period of bed rest. Pain medication may be given for pain or discomfort related to the insertion site or having to lie flat and still for a prolonged period. The patient will be encouraged to drink water and other fluids to help flush the contrast dye from the body. Normal diet may be resumed after the procedure, unless the doctor decides otherwise.

The patient will most likely spend the night in the hospital after the procedure. Depending on the patient’s condition and the results of the procedure, hospital stay may be longer.

Rehabilitation

Once at home, the insertion site should be monitored for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the insertion site. A small bruise is normal. If a constant or large amount of blood is noticed at the site that cannot be contained with a small dressing, the doctor needs to be notified.

If a closure device has been used for the insertion site, specific information will be given regarding the type of closure device that was used and how to take care of the insertion site. There may be a small knot, or lump, under the skin at the site. This is normal. The knot should gradually disappear over a few weeks. It will be important to keep the insertion site clean and dry. Specific bathing instructions will be given. . The patient will be advised not to participate in any strenuous activities for a period of time after the procedure.

The doctor needs to be notified in case of the 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

Risks / Complications

Although over 95% of percutaneous coronary intervention procedures are successful, there are a few patients that still have problems. For example, sometimes the catheter (or its guide wire) cannot get through the narrowed lumen, or a thrombus (blood clot) forms at the site if the inner lining of the artery tears at the balloon site.
Current percutaneous coronary intervention mortality is less than 1%. Some patients may develop an aneurysm in the artery at the catheter entry site. Most patients will experience some bruising and tenderness at the catheter entry site.

Outlook

As the percutaneous coronary intervention technique has advanced from balloon, to balloon plus stent, to balloon plus drug-eluting stent, the long-term results have improved so recurrent narrowing or blockage occurs in less than 10% of patients. If there is no evidence of recurrence of narrowing or blockage (for example, a negative stress test) after about 12 months, the majority of stented coronary arteries remain open in the stented area for many years.
Also, patients that fail to take their prescribed anti-platelet medication and continue a lifestyle that promotes coronary artery cholesterol accumulation and arterial narrowing are more likely to have either stent failure or have additional arterial areas develop narrowing or blockage.

Percutaneous coronary intervention (PCI) is performed to open blocked coronary arteries caused by coronary artery disease (CAD) and to restore arterial blood flow to the heart tissue without open-heart surgery. Percutaneous coronary intervention is performed by inserting a catheter through the skin in the groin or arm into an artery. At the leading tip of this catheter, several different devices such as a balloon, stent, or cutting device (artherectomy device) can be deployed. The catheter and its devices are threaded through the inside of the artery back into an area of coronary artery narrowing or blockage.
Percutaneous coronary intervention can be used to relieve or reduce angina, prevent heart attacks, alleviate congestive heart failure, and allows some patients to avoid surgical treatment (coronary artery bypass graft or CABG) that involves extensive surgery and often long rehabilitation time.

Balloon angioplasty employs a deflated balloon-tipped narrow catheter that is inserted through the skin of the groin or arm into an artery. The catheter is threaded through the artery until it arrives in the coronary artery where there is narrowing or blockage. The catheter tip is then inserted through the narrowed area. Once in the narrowed area, the balloon is inflated, mashing the plaque into the vessel walls to reduce the narrowing.
The balloon is then deflated and the catheter removed. The process is viewed by injecting a dye that allows the cardiologist to view the flowing blood as it goes through the arteries. This viewing method (angiogram) can be used to assure that the artery has increased blood flow after the balloon is deflated and removed.

A stent is an extendable metal scaffold that can be used to keep open previously narrowed coronary arteries after angioplasty has been performed. The mechanism used to place the stent in a narrowed or blocked coronary artery is very similar to balloon angioplasty. The difference is that the un-extended or collapsed stent surrounds the balloon. The stent surrounding the balloon is expanded when the balloon is inflated. After the stent surrounding the balloon extends, it locks into place against the plaque/arterial vessel wall. The stent stays inside the artery after the balloon is deflated. Stents are useful because they keep the coronary artery open when the balloon is deflated, preventing most arteries from narrowing again (termed elastic recoil) after the balloon is deflated. Recurrent narrowing (restenosis) sometimes may still occur after the stent is placed due to formation of scar tissue.

The newest stents are termed drug-eluting stents. These stents are covered in a drug that slowly comes off the stent and prevents cell proliferation (scarring or fibrosis) at the stent site more effectively than uncoated, bare-metal stents.

The major problem that develops with coronary arteries is the narrowing of their inner passageway (lumen), which in turn restricts, or in severe situations stops the flow of blood to the heart muscle. This restriction or stoppage of blood flow causes heart muscle damage or death because of lack of oxygen. If the occluded coronary artery is a small branch, it is possible that only a small segment of heart muscle will be injured or die, but the person will likely survive. If the occluded artery is large, death is more likely. Angina or chest pain occurs when a coronary artery becomes occluded enough to cause a reduced blood flow that does not meet the demand for oxygen required by the heart muscle.

The most frequent cause of coronary artery narrowing is cholesterol deposits (plaques) that build up in the arteries. Limiting cholesterol in the diet or by slowing its synthesis by the body with medication (or both) are major ways to help limit arterial narrowing. Many other factors may play a role in coronary heart disease such as genetics, disease such as diabetes, lifestyles such as choosing to smoke, and even drug abuse such as using cocaine.

Treatment of coronary artery disease centers around one main issue – the inadequate blood flow in the coronary arteries cannot meet the oxygen demand of the heart muscle. To prevent heart attacks, diet modification and medications (some designed to reduce cholesterol, others to reduce oxygen demand) are used. Mechanical methods, such as percutaneous coronary intervention and CABG (coronary artery bypass grafts) are procedures used to open the narrowed blood vessels of coronary artery disease.

Although over 95% of percutaneous coronary intervention procedures are successful, there are a few patients that still have problems. For example, sometimes the catheter (or its guide wire) cannot get through the narrowed lumen, or a thrombus (blood clot) forms at the site if the inner lining of the artery tears at the balloon site. Although agents are used to chemically prevent clot formations, not all treatments are successful. About 1%-2% of current percutaneous coronary intervention procedures fail and may require emergent CABG surgery. The risk of a heart attack is about 1%-2% in people that have percutaneous coronary intervention.
Current percutaneous coronary intervention mortality is less than 1%. Some patients may develop an aneurysm in the artery at the catheter entry site. Most patients will experience some bruising and tenderness at the catheter entry site.

As the percutaneous coronary intervention technique has advanced from balloon, to balloon plus stent, to balloon plus drug-eluting stent, the long-term results have improved so recurrent narrowing or blockage occurs in less than 10% of patients. If there is no evidence of recurrence of narrowing or blockage (for example, a negative stress test) after about 12 months, the majority of stented coronary arteries remain open in the stented area for many years. Unfortunately, other areas of the artery may require an additional stent in the future. Also, patients that fail to take their prescribed anti-platelet medication and continue a lifestyle that promotes coronary artery cholesterol accumulation and arterial narrowing are more likely to have either stent failure or have additional arterial areas develop narrowing or blockage.

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