Angioplasty, coronary

Page last reviewed: 13/07/2011

A coronary angioplasty is a surgical procedure that is used to widen blocked or narrowed coronary arteries. Coronary angioplasty is sometimes known as percutaneous transluminal coronary angioplasty or percutaneous coronary intervention.

The coronary arteries

Like all organs in the body, the heart needs a constant supply of blood. This is supplied by two large blood vessels called the left and the right coronary arteries. In older people, these arteries can become narrowed and hardened.

Hardening of the coronary arteries can result in angina. Angina is a syndrome (a collection of symptoms caused by an underlying health condition) that is caused when the supply of oxygen-rich blood to the heart becomes restricted.

The most common symptom of angina is chest pain, which is usually triggered by physical activity. While many cases of angina can be treated with medication, severe symptoms of angina may require a coronary angioplasty to restore the blood supply to the heart.

Coronary angioplasties are also often used as an as emergency treatment following a heart attack.

Stents

Angioplasty involves using a catheter (a flexible tube) to insert a stent into the coronary artery. A stent is a short, hollow metal tube.

A small balloon is inflated to open the stent, which pushes against the artery walls. This widens the artery, squashing fatty plaques against the artery wall so that blood can flow through it more freely.

See How it is performed for more information about stents.

How common are coronary angioplasties?

Coronary angioplasties are one of the most common types of heart surgery. Approximayely 3000 procedures are performed in Ireland each year.

Due to the associated risk factors for angina, coronary angioplasties are most commonly performed in people who are 65 years of age or older.

Safety

As with all surgical procedures, a coronary angioplasty carries the risk of complications, such as post-operative infection or bleeding.

Serious complications, such as a blood clot or heart attack, are uncommon and occur in an estimated 1 in 100 cases.

Angina

Angina is chest pain caused by a reduced flow of blood to the heart, typically resulting from heart disease.
Arteries
Arteries are blood vessels that carry blood from the heart to the rest of the body.
Heart attack
A heart attack happens when there is a blockage in one of the arteries in the heart.

Page last reviewed: 13/07/2011

Atherosclerosis

A coronary angioplasty is necessary when hardening and narrowing of the coronary arteries prevents the heart from getting enough blood to function normally. Hardening of the arteries is known as atherosclerosis.

Your arteries harden and narrow naturally as you get older, but this process can be dangerously accelerated by:

  • eating a high-fat diet
  • smoking
  • high blood pressure (hypertension)
  • diabetes
  • ethnicity (where you were born and your cultural background)

For reasons that are not fully understood, high blood pressure and atherosclerosis are more common among people of African-Caribbean and south Asian (Indian, Pakistani, Bangladeshi and Sri Lankan) origin.

Angina

Once the hardening and narrowing of your coronary arteries reaches a certain point, your heart no longer receives the blood supply it needs to work properly. This can trigger the symptoms of angina, including:

  • pain or discomfort in your chest
  • breathlessness
  • nausea
  • fatigue
  • dizziness
  • belching (burping)
  • restlessness

The onset of symptoms of angina is sometimes called an angina attack.

There are two types of angina:

  • stable angina, where symptoms only last a few minutes, are triggered by physical activity and can be relieved with medication, and
  • unstable angina, where symptoms develop even when you are resting, last longer than five minutes and cannot usually be relieved with medication

Medication is usually the first treatment option for stable angina. If your symptoms fail to respond to the medication, a coronary angioplasty may be recommended.

The recommended treatment for unstable angina depends on the results of testing. An electrocardiogram (ECG) may be used to record the rhythms and electrical activity of your heart.

If the results of your ECG suggest that your coronary arteries are severely narrowed, you may need a coronary angioplasty.

Heart attack

A coronary angioplasty can be used as an emergency treatment for a heart attack if the heart attack was caused by an interruption to your heart's blood supply.

If you have angina...

An angioplasty can:

  • relieve your pain
  • reduce your need for angina medication
  • ease symptoms such as breathlessness
  • enable you to be more active
  • improve your ability to do everyday activities, such as climbing stairs and walking any distance
  • reduce your risk of having a heart attack
  • make you feel generally better so you're more able to do the things you want to do, such as going to work and enjoying a social life

If you've had a heart attack...

An angioplasty can:

  • increase your chances of surviving by a third more than with clot-busting treatment (thrombolysis)
  • reduce your chances of having another heart attack

Seven in 100 people who have clot-busting drugs will die, compared with five in 100 people who have angioplasty.

Page last reviewed: 13/07/2011

A coronary angioplasty is a non-invasive form of surgery. This means that it does not involve making major incisions in the body. Therefore, it can usually be performed safely in most people.

However, if you have an unrelated serious health condition, such as cancer or liver failure, the risks of treatment may outweigh the benefits.

A coronary angioplasty may not be technically possible if the anatomy of your arteries is different from normal, for example if there are too many narrow sections in your arteries or lots of branches coming off your arteries that are also blocked.

In this circumstance, an alternative surgical procedure, known as a coronary artery bypass graft (CABG), may be considered. See Alternatives for more information about CABG.

Page last reviewed: 13/07/2011

You may have an appointment for a pre-assessment of your health a few days before the operation date. This might involve some blood tests and a general health check to make sure you are fit for surgery. If you have a pre-assessment appointment, you can use this as an opportunity to discuss any concerns with your surgeon.

How can I prepare for treatment?
Being as fit as you can be before your angioplasty can aid your recovery. Your cardiologist can advise you on the precise steps to take. Advice may include:

  • Quit smoking. Smoking increases the risk of infection and can delay healing after any surgical procedure. It can also increase your risk of blood clots.
  • Watch your weight. If you are overweight, the surgeon may advise you to slim down. Your GP or a dietitian can give you advice on healthy eating.
  • Moderate alcohol. Too much alcohol can affect the function of your heart. Cutting down before you come into hospital will improve your overall health.
  • Stay active. Staying as active as possible can help you make a better recovery. Try to exercise for at least half an hour every day. Walking, swimming and even gardening are good forms of exercise.
  • Stock up. Buy food that is easy to prepare, such as frozen ready meals, cans and staples such as rice and pasta, or prepare your own dishes to freeze and reheat during your recovery.
  • Clean up. Before going into hospital, have a good long bath or shower, cut your nails (don't forget to take off any nail polish) and wash your hair. Put on freshly washed clothes. This helps prevent unwanted bacteria coming into hospital with you and complicating your care.
  • Think positive. A positive mental outlook can help you deal with the stress of surgery and aid your recovery.

If you know that you have problems with your blood pressure, heart or lungs, ask your family doctor to check that these are under control. Bring all your tablets and medicines with you to the hospital, and check the hospital's advice about taking the Pill or hormone replacement therapy (HRT).

On the ward, you may be checked for past illnesses and may have special tests to ensure you are well prepared and can have the operation as safely as possible. Many hospitals now run special preadmission clinics, where you visit for an hour or two a few weeks before the operation to have these checks.

Find a relative or friend who can come with you to the hospital, take you home and look after you for the first week after the operation.

What should I take into hospital?

  • a change of nightclothes
  • comfortable clothing that's easy to put on
  • Toiletries
  • Medications
  • A plastic bag with bulldog clip. Clip the bag to your sheet for your personal rubbish
  • Books, iPod, stationery, jigsaws, crosswords etc to help pass the time during your recovery
  • healthy snacks for between meals
  • your address book and important phone numbers

Page last reviewed: 13/07/2011

Preparation

Before a coronary angioplasty can be carried out, it is necessary to study the arteries near your heart to make sure that the surgery is technically possible. This is done using a test called a coronary angiography.

During a coronary angiography, a long, flexible, hollow plastic tube called a catheter (about the width of the lead in a pencil) is inserted into a blood vessel, either in your groin or arm.

The tip of the catheter is guided under X-ray to your heart or the arteries that supply your heart. A special fluid, known as contrast medium, is injected through the catheter. Contrast medium is a dye that is visible on an X-ray. The pictures that are produced are called angiograms.

If the results of your angiogram show that surgery can go ahead, you will be given an appointment for surgery.

You may be asked not to eat or drink anything for four hours before surgery begins. You will usually be able to take most medications as normal up to the day of your surgery, with the exception of blood-thinning medications such as warfarin. Your surgical team can give you more information about this.

A coronary angioplasty usually involves an overnight stay in hospital. After the procedure, you will need to arrange for someone to drive you home from hospital. You will be unable to drive for around a week after the procedure.

The procedure

A coronary angioplasty is usually performed in a room called a catheterisation laboratory, rather than in an operating theatre. A catheterisation laboratory is a room that is fitted with a high-resolution (X-ray) video, or sometimes ultrasound, to allow the doctor to monitor the procedure on a television screen.

The procedure usually takes about 30 minutes, although it may take longer depending on how many sections of your artery need to be treated.

You will be asked to lie on your back on an X-ray table. An intravenous (IV) line will be inserted into a vein, in case you need to have painkillers or a sedative. You will then be attached to a heart monitor and given a local anaesthetic to numb your skin.

The surgeon will make a small incision (cut) in the skin of your groin or wrist, and will insert the balloon-tipped catheter (a thin, flexible tube). The surgeon will guide the catheter up through the artery in your groin (or arm), passing it through the main artery in your body (the aorta) and into the opening of your left or right coronary artery.

When the catheter reaches the narrowed part of your coronary artery, the surgeon will inflate the balloon. This will squash the fatty material on the inside walls of your blocked artery in order to widen it. This will be done several times.

If you are having a stent inserted (see below), it will open up as the balloon is inflated and will be left inside your artery.

The surgeon will check that your artery is wide enough to allow blood to flow through more easily. They do this by injecting a small amount of contrast dye into the catheter and watching it flow through the artery. They will then deflate the balloon and withdraw the catheter.

You will not be able to feel the catheter when it is inside the blood vessel, but you may feel an occasional missed or extra heartbeat. This is nothing to worry about and is completely normal.

Stents

A stent is a short, wire mesh tube that acts like a scaffold to help keep your artery open. There are two main types of stent:

  • bare metal (uncoated) stent, and
  • drug-eluting stent, which is coated with medication that reduces the risk of the artery becoming blocked again

The biggest drawback of using bare metal stents is that, in around 30% of cases, the arteries begin to narrow again. This is because the immune system sees the stent as a foreign body and attacks it, causing inflammation (swelling) and excessive tissue growth around the stent.

Many cardiologists (heart specialists) avoid this problem by using drug-eluting stents. These are coated with medication that reduces the body's inflammatory response and tissue growth.

Once the stent is in place, the medication is released over time into the area that is most likely to become blocked again. The two most researched types of medication are:

  • sirolimus, which is usually used to prevent rejection in organ transplants, and
  • paclitaxel, which reduces the production of platelets (the red blood cells that help the blood to clot)

The use of drug-eluting stents has reduced the rate of arteries re-narrowing from around 30% to well below 10%. However, as drug-eluting stents are still a relatively new technology, it is uncertain how effective or safe they are in the long term.

Before your procedure, discuss the benefits and risks of each type of stent with your surgical team.

How can I decide where to get treatment?

Look for a cardiac centre that does a large number (at least 500) of angioplasties each year. Doctors call this a high-volume centre. Choose a cardiologist (heart specialist) who does a high number of angioplasties (more than 100 to 200 a year). These specialists are known as 'interventional cardiologists'.

Page last reviewed: 13/07/2011

Leaving hospital

You will normally be able to leave hospital the day after having a coronary angioplasty. Arrange for a friend or family member to take you home.

Before leaving hospital, you will be told about any medication that you need to take (see below) and you may receive advice about improving your diet and lifestyle. You will also be given a date for a follow-up appointment to check on your progress.

You may have a bruise under the skin where the catheter was put in. This is not serious, but it may be sore for a few days. Occasionally, the small wound where the catheter was inserted can become infected. Keep an eye on the wound to check that it is healing properly. Tell your GP if it becomes red and sore.

Returning home

After having a coronary angioplasty, avoid doing any heavy lifting for about a week or until the small wound from the catheter has healed.

Do not drive for a week after the operation. If you drive a heavy vehicle for a living, such as a lorry or a bus, do not drive for at least six weeks. After this time, you should be able to drive again as long as:

  • you meet the requirements of an exercise/function test, and
  • you do not have another disqualifying health condition

If you have had a planned coronary angioplasty, you should be able to resume your normal activities within a week. However, if you have had an emergency angioplasty following a heart attack, it may be several weeks or months before you recover fully.

Sex

If your sex life was previously affected by angina, you may find that, following a coronary angioplasty, you can resume a more active sex life as soon as you feel ready. If you have any concerns, your GP will be able to reassure you. According to experts, having sex is the equivalent of climbing a couple of flights of stairs in terms of the strain that it puts on your heart.

Further treatment

Most people need to take blood-thinning medication for at least six months after having an angioplasty. This is usually a combination of low-dose aspirin and a medication called clopidogrel.

Clopidogrel blocks one of the chemicals that the body uses to trigger blood clotting.

Common side effects of clopidogrel include:

  • diarrhoea
  • indigestion
  • abdominal pain
  • excessive or unusual bleeding, such as bleeding when injected, nosebleeds or blood in your urine (the loss of blood is usually minimal and nothing to worry about)
  • your skin may bruise more easily

Due to the side effect of excessive bleeding, men may find it more convenient to shave with an electric razor.

The course of clopidogrel will be withdrawn after the agreed time period, but you may need to continue taking low-dose aspirin for the rest of your life.

You may need to have another angioplasty if your artery becomes reblocked and your angina symptoms return. Alternatively, you may need a coronary artery bypass graft (CABG).

Glossary

Angina
Angina is chest pain caused by a reduced flow of blood to the heart, typically resulting from heart disease.
Arteries
Arteries are blood vessels that carry blood from the heart to the rest of the body.
Catheter
A catheter is a thin, hollow tube, usually made of rubber, that is placed into the bladder to inject or remove fluid.
Coronary artery bypass
A heart (coronary) bypass is surgery to redirect the flow of blood around a clogged artery by creating a new pathway for the blood to travel in.
Heart
The heart is a muscular organ that pumps blood around the body.

Lifestyle changes

  • If you do have angioplasty, you'll still need to take tablets.
  • It's also important that you try to lose weight if you're overweight.
  • If you're a smoker, try to quit 

Smoking and being overweight are two of the main causes of heart disease. They also make treatment less likely to work.

Page last reviewed: 13/07/2011

As with all surgery, coronary angioplasty carries a risk of complications. A number of factors increase your risk of complications, including:

  • Your age. The older you are, the higher the risk. For example, a 60-year-old man (with no other associated risk factors) has a less than 1% risk of developing complications, while an 80-year-old has a 3% risk.
  • Whether the surgery was planned for angina or performed as an emergency following a heart attack. Emergency surgery is always riskier because there is less time to plan it.
  • Whether you have kidney disease. The intravenous dye that is used during an angioplasty can occasionally cause further damage to your kidneys. 
  • Whether more than one coronary artery has become blocked. This is known as multi-vessel disease.
  • Whether you have a lesion in your coronary artery. A coronary artery lesion is a soft lump of cholesterol that can form inside the artery.
  • Whether you have a history of serious heart disease.

Depending on which risk factors apply to you, the risk of having a complication after an angioplasty can range from less than one in a hundred to one in three.

Your surgical team can give you more information about your individual circumstances and level of risk.

Complications that can occur after an angioplasty include:

  • heart attack, which is estimated to occur in 1 in 100 cases
  • stroke, which is estimated to occur in 1 in 200 cases
  • excessive bleeding after the operation, which is estimated to occur in 1 in 200 cases and requires a blood transfusion to treat
  • death, which is estimated to occur in 1 in 500 cases

Glossary

Allergic
An allergen is a substance that reacts with the body's immune system and causes an allergic reaction.
Artery
Arteries are blood vessels that carry blood from the heart to the rest of the body.
Catheter
A catheter is a thin, hollow tube, usually made of rubber, that is placed into the bladder to inject or remove fluid.
Heart
The heart is a muscular organ that pumps blood around the body.
Heart attack
A heart attack happens when there is a blockage in one of the arteries in the heart.
X-ray
An X-ray is a painless way of producing pictures of inside the body using radiation.

Page last reviewed: 13/07/2011

The most widely used surgical alternative to a coronary angioplasty is a coronary artery bypass graft (CABG).

Coronary artery bypass graft

CABG is surgery to bypass a blockage in an artery using segments of healthy blood vessel (grafts) taken from other parts of the body. Segments of vein from your legs or chest are used to create a new channel through which blood can be directed past the blocked part of the artery. This allows more blood to get through into the heart muscle.

Complications of CABG are uncommon, but are potentially serious. They include:

  • heart attack, which is estimated to occur in 1 in 50 cases
  • stroke, which is estimated to occur in 1 in 50 cases

You may not always be able to choose between having a coronary angioplasty or a CABG.

CABG is usually recommended when multiple coronary arteries have become blocked and narrowed. However, it is invasive surgery so may not be suitable for people who are particularly frail and in a poor state of health.

A coronary angioplasty may not be possible if the anatomy of the blood vessels near your heart is abnormal.

Coronary angioplasty or CABG?

If you are able to choose between having a coronary angioplasty or a CABG, be aware of the advantages and disadvantages of each technique.

As a coronary angioplasty is non-invasive, you will recover from the effects of the operation quicker than you will from CABG. The procedure also has a lower complication rate.

However, research has shown that one in four people who have a coronary angioplasty require further surgery because the widened artery narrows again. However, the number of people who need further surgery will probably fall sharply in the future due to the use of drug-eluting stents.

CABG has a longer recovery time than coronary angioplasty and a higher complication rate. However, only 1 in 10 people who have a CABG require further surgery. Also, research published in 2009 found that CABG is usually a more effective treatment option for people who are over 65 years of age and for those with diabetes.

Discuss the benefits and risks of both types of surgery with your surgical team.

Percutaneous transluminal coronary rotational atherectomy (PTCRA)

Percutaneous transluminal coronary rotational atherectomy (PTCRA) is a similar technique to coronary angioplasty. However, rather than using a balloon and a stent to expand the artery, a small diamond cutter is used to remove the plaque that is blocking the artery.

Evidence has found that PTCRA is no more effective than a coronary angioplasty so it is usually only carried out in people who are not suitable for coronary angioplasty.

Page last reviewed: 13/07/2011

Coronary angioplasty is carried out as a planned procedure, or as a form of emergency treatment.

Planned coronary angioplasty

Coronary angioplasty is not suitable for everyone with angina. Therefore, your GP will first of all refer you to a cardiologist (heart specialist) for some tests, which include:

  • blood tests,
  • an electrocardiogram (ECG) - an electrical recording of your heart to measure how well it is working, and
  • a coronary angiogram - used to find the blockages in your coronary arteries.

A catheter (thin, flexible tube) is gently inserted into your coronary artery and a special dye is injected which shows up on X-ray pictures to highlight any blockages. The specialist will use the test results to determine the most suitable form of treatment for you. About three in every 10 people who have a coronary angiogram go on to have a coronary angioplasty.

If there are too many narrow sections in your arteries, or if there are lots of branches coming off the arteries that are also blocked, a coronary angioplasty may not be possible. In such cases, alternative operations such as a coronary artery bypass may be considered (see box).

Emergency coronary angioplasty

Coronary angioplasty may sometimes be used to treat people who have acute coronary syndrome, such as a heart attack or unstable angina. If you have unstable angina, you will experience chest pain even while you are resting. Emergency coronary angioplasty and planned coronary angioplasty use the same procedure, although if you have acute coronary syndrome, you may require additional medication when the angioplasty is carried out.

Coronary artery bypass

This is a procedure that allows the blood flowing through your coronary artery to bypass (get round) the part of the artery that is blocked. To do this, an artery from another area of your body, such as your chest wall, is taken and one end is grafted (attached) below the blockage and the other end above the blockage.

A coronary angioplasty may be a suitable procedure if you have previously had a coronary artery bypass. If the 'grafted' blood vessels become blocked, a coronary angioplasty may be used to widen them.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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