Coronary Angioplasty

Angioplasty is a generic term used to treat atherosclerotic narrowings in the arteries of our body or occasionally some narrowings in the veins, by means of dilation of same with a balloon catheter and if need be put in a stent i.e. a metallic scaffolding in its place.

Thus angioplasty can be done for the heart arteries, in the brain arteries, renal arteries, peripheral limb arteries or veins etc.

Emergency Coronary Angioplasty (PAMI)

PAMI or primary angioplasty in myocardial infarction is an emergency, life-saving procedure done to treat STEMI (ST elevation myocardial infarction) or acute heart attacks. In this the patients upon diagnosing this condition are immediately taken up in the cath lab, angiography is performed to diagnose the blocked artery and immediate angioplasty is performed to relieve the blockage.

Planned Angioplasty

Patient and the relatives are explained about the procedure and proper consent is taken. Pre-procedure injections are given and the patient is shifted to the cardiac cath lab. Angiography is performed normally via a sheath in the wrists i.e. radial artery or the groins i.e. the femoral artery. This procedure is normally done under local anaesthesia only.

In the cath lab, the patient normally lies flat and a catheter is inserted through the sheath. The catheter passes through the arteries and into the mouth of the coronary i.e. the heart arteries and dye is injected through it with a camera over the patient taking pictures of the heart arteries.

Post the angiogram, we discuss the need for further treatment depending on the findings. If the arteries have significant lesions or blockages, then we could proceed with angioplasty i.e. balloon dilation of the lesion and then further putting in stents.

Once angiography confirms the need for angioplasty, we proceed with the same.

• A bigger catheter is used for angioplasty, than the ones used for angiography.
• The catheter is kept at the mouth of the coronary arteries.
• Subsequently, a wire is passed from the tube into the coronary artery and across the lesion which needs to be treated.
• Then a balloon catheter is inserted over the wire and placed across the lesion site and expanded across it. This leads to disruption of the lesion site and opening of the blockage.
• Then a stent is inserted over the wire and placed at the lesion site and expanded across it to keep the artery open. If needed, these stents can be further expanded by bigger-sized balloon catheters.
• Once done, further angiograms are taken to check for procedure results. If all looks fine, then the wire and catheters are taken out and the patient is monitored for a day or two and then discharged home.

With the modern advancements, more and more difficult cases can be dealt with angioplasty and open heart surgery can be avoided.

Some advances in angioplasty to name a few are as follows -

• Calcium modification - If the blockages have significant calcium, then various types of balloons like cutting balloons or scoring balloons can be used. If more calcific, then IVL i.e. intravascular lithotripsy balloon catheters can be used. These cause calcium modification via sonic pressure waves. Also, rotablation burrs i.e. akin to drills can also be used in very calcific lesions to modify them.
• Coronary imaging - IVUS (Intravascular ultrasound) and OCT (Optical coherence tomography) are special catheters which can be placed in the heart arteries to look at the vessels more closely. These advances help to perform more complex procedures like left main stenting or to treat in-stent restenosis with more confidence.
• Minimal contrast angioplasty - In patients with kidney disease, where you cannot inject a lot of dye, IVUS catheters can help plan the procedure in terms of the vessel caliber, length and size of stent to be used and thus avoid a lot of contrast and saving these patients from undergoing hemodialysis.

Once angiography confirms the need for angioplasty, we proceed with the same.

• A bigger catheter is used for angioplasty, than the ones used for angiography.
• The catheter is kept at the mouth of the coronary arteries.
• Subsequently, a wire is passed from the tube into the coronary artery and across the lesion which needs to be treated.
• Then a balloon catheter is inserted over the wire and placed across the lesion site and expanded across it. This leads to disruption of the lesion site and opening of the blockage.
• Then a stent is inserted over the wire and placed at the lesion site and expanded across it to keep the artery open. If needed, these stents can be further expanded by bigger-sized balloon catheters.
• Once done, further angiograms are taken to check for procedure results. If all looks fine, then the wire and catheters are taken out and the patient is monitored for a day or two and then discharged home.

Indications to perform an angioplasty are mainly elective and emergency.

If a patient is having an acute heart attack, an urgent angiography is done to diagnose the occluded artery with the intention to open it up in the form of angioplasty and putting in stents.

If a patient complains of symptoms of chronic stable angina, then an elective angiography can be done if symptoms are refractory to medicines. Based on the angiography findings, the decision can be taken to undergo angioplasty or consider CABG (coronary artery bypass grafting) i.e. open heart surgery.

Diagnostics

Prior to proceeding with angioplasty, it is prudent to get as much information as possible about the heart function. Patients' symptoms are the most important in deciding the line of management. In forms of other investigations, ECG (electrocardiogram), ECHO (echocardiogram), Stress test and angiogram are essential in decision making and planning the angioplasty procedure.

Immediate Post-Procedure Care

Patients are usually shifted to the ICU post procedure to observe for any chest pain or ECG changes. Local site i.e. the radial site or femoral site, from where the procedure is performed is monitored. Blood thinning medicines and injections are given as needed.

Medication Regimen and Lifestyle Changes

It is very important to know that medicines and lifestyle play an equally important role in coronary artery disease. Long term outcomes of angioplasty or CABG are very much dependent on the compliance of medicines and adopting changes in lifestyle which includes a good balanced diet and exercise regimen.

Rehabilitation Programs and Follow-Up Visits

For recuperating from heart disease post the procedure, we offer curated rehabilitation programs that help patients to get back to their routine life sooner. There is good evidence that patients who religiously enrol in rehabilitation programs tend to do well in the long term as compared to patients who opt out of it.

We usually advise patients to come for follow-up a week and then one month post procedure. Thereafter we see them every 3 months for the 1st year and then bi-yearly follow up throughout life. Some blood tests, ECG, and ECHO may be advised on follow-ups as needed. Some patients may be asked to come for follow-ups more frequently depending on the findings by the doctors or if the patients are symptomatic.

Coronary angioplasty offers a minimally invasive option to treat the blockages in the arteries supplying your heart. It avoids opening up the chest, avoids general anesthesia, and requires very little recovery time compared to CABG.

In the western countries, this procedure has become like a day care procedure, with patients getting admitted in the morning, observed for a few hours post-procedure, and sent home if ECG is fine and has no symptoms.

Stents are metallic tubes, made of different materials like cobalt, chromium, platinum or a combination of them, depending on the stent platform. Additionally, they also have a drug coating around them to prevent early restenosis at the insertion site. Basically, these stents are a mesh-like tube inserted in the arteries to keep them open with their radial strength.

Nowadays only drug coated stents are used routinely and bare metal stents (non drug coated ones) are almost obsolete and are hardly ever used. Various companies both Indian and International ones manufacture stents. All these stents have their own advantages and drawbacks, so it is prudent to talk to your cardiologist regarding the stent they would be choosing in the angioplasty.

If you have an acute pain in your chest, it is better to reach your closest hospital where there is a facility for doing the angioplasty procedure. If not urgent, you could go to any cardiologist and hospital as per your convenience.