Coronary angioplasty and stenting: Opening clogged arteries

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Coronary angioplasty and stenting: Opening clogged heart arteries

Coronary angioplasty can reopen clogged heart arteries and improve your symptoms.

Coronary angioplasty, also referred to as percutaneous coronary intervention (PCI), is a medical procedure used to open clogged heart arteries.

Coronary angioplasty can improve some of the symptoms associated with blocked arteries, such as chest pain and shortness of breath, or can be used during a heart attack to quickly open a blocked artery and minimize heart damage.

Angioplasty (AN-je-o-plast-tee) involves temporarily inserting and expanding a tiny balloon at the site of your blockage to help widen a narrowed artery. Angioplasty is usually combined with implantation of a small metal coil called a stent in the clogged artery to help prop it open and decrease the chance of it narrowing again (restenosis).

Coronary angioplasty has become a common medical procedure with more than 1 million done in the United States every year.

Who is angioplasty for?

When medications or lifestyle changes aren't enough to reduce the effects of artery blockages, or if you have a heart attack, worsening chest pain or other symptoms, your doctor might suggest angioplasty. First you'll have an imaging test called a coronary angiogram to determine if your blockages can be treated with angioplasty.

You may be a good candidate for an angioplasty if:

  • Your blockage is small
  • Your blockage can be reached by angioplasty
  • The artery affected isn't the main vessel supplying blood to the left side of your heart
  • You don't have heart failure

If the main artery supplying the left side of your heart is narrowed, if your heart muscle is weak or if you have small, diffusely diseased blood vessels, then coronary artery bypass surgery (CABG) may be a better option. In addition, if you have diabetes and multiple blockages, your doctor may suggest coronary artery bypass surgery. The decision of angioplasty versus bypass surgery will depend on the details of your heart disease and overall medical condition.

Coronary artery plaques

Illustration of coronary artery plaques

Atherosclerosis (ath-ur-o-skluh-RO-sis) is hardening and narrowing of the arteries caused by the accumulation of fatty deposits (plaques) and other substances. A blood clot also may form at the site, completely blocking your artery and causing a heart attack.

Who performs an angioplasty?

Angioplasty is performed by a heart specialist (cardiologist) and a team of specialized cardiovascular nurses and technicians, usually in a cardiac catheterization laboratory. Ideally, an angioplasty will be done only at a medical institution with backup cardiac surgical facilities or access to rapid emergency transport services because of a small risk of complications that could require emergency heart surgery.

Generally, the more practice in doing a procedure, the better the outcome. Research has shown the best angioplasty outcomes are those done by doctors who do at least 75 angioplasties a year and in hospitals that perform at least 400 angioplasties annually.

Stents provide added support

Once the artery is widened, a device called a stent is usually placed in the artery to act as scaffolding to help prevent it from re-narrowing after the angioplasty. The stent looks like a very tiny coil of wire mesh. Stents can be coated with medication that's slowly released to help prevent arteries from re-clogging. These coated stents are called drug-eluting stents, in contrast to noncoated versions, which are called "bare-metal" stents.

Here's what happens:

  • The stent is collapsed, placed around a balloon at the tip of the catheter and guided through the artery to the blockage.
  • At the blockage, the balloon is inflated and the spring-like stent expands and locks into place inside the artery.
  • The stent remains in the artery permanently to hold it open and improve blood flow to your heart.
  • Once the stent is in place, the balloon catheter is removed and more images (angiograms) are taken to see how well blood flows through your newly widened artery.
  • Finally, the guide catheter is removed and the procedure completed.

After your stent placement, you may need prolonged treatment with medications to reduce the chance of blood clots forming on the stent material.

Results

For most people, coronary angioplasty greatly increases blood flow through the previously blocked artery. Your chest pain should subside, and you may have a better ability to exercise.

Lifestyle modifications will help you maintain your good results, including:

  • Stopping smoking
  • Lowering your cholesterol levels
  • Maintaining a healthy weight
  • Controlling other conditions, such as diabetes and high blood pressure
  • Getting regular exercise

Successful angioplasty also means you might not have to undergo a more invasive surgical procedure called coronary artery bypass surgery. In a bypass, an artery or a vein is removed from a different part of your body and sewn to the surface of your heart to take over for the blocked coronary artery. This surgery requires a large incision in the chest. Recovery from bypass surgery is usually longer and more uncomfortable.

If you have many blockages or narrowing of the main artery leading to the heart, reduced heart function, or diabetes, then your doctor may recommend bypass surgery instead of angioplasty and stent placement. In addition, for technical reasons some blockages may be better treated with bypass surgery.

Risks of angioplasty

Restenosis. Angioplasty isn't without some risks. A major drawback of coronary angioplasty is the potential for your artery to re-narrow (restenosis) within months of the procedure. With angioplasty alone — without stent placement — restenosis happens in as many as 30 percent to 40 percent of cases. Stents were developed to reduce restenosis. The original bare-metal stents reduce the chance of restenosis to less than 20 percent, and the use of drug-eluting stents has reduced the risk to less than 10 percent.

Blood clots. Recent studies have raised concern about the risk of blood clots forming within stents long term — meaning weeks or months after angioplasty. These clots may cause a heart attack — the exact opposite goal of angioplasty. Some studies have suggested that drug-eluting stents increase this clotting risk, compared with bare-metal stents, but the findings of other studies have not been conclusive. This issue is being studied by the Food and Drug Administration (FDA). Because drug-eluting stents are relatively new, long-term results are not yet available. Regardless of the type of stent placed, it is absolutely necessary to take aspirin, clopidogrel (Plavix) and other medications as prescribed to decrease the chance of clots forming in the stent.

Other risks of angioplasty include:

  • Bleeding. You may experience heavy bleeding, requiring a transfusion or other medical procedures.
  • Damage. Your artery may be damaged during the procedure, requiring emergency bypass surgery.
  • Heart attack. You may have a heart attack during the procedure, though large heart attacks are rare.
  • Ongoing disease. The procedure doesn't fix the underlying cause of the blocked artery, which means other parts of the artery and other arteries can become blocked.

What's ahead

Ongoing research is helping find new techniques and medications to improve coronary angioplasty. Stent technology continues to advance, and new and better medications used in conjunction with angioplasty could help by shrinking blockages, decreasing the risk of re-blockage, and preventing blood clots and other complications.

Last Updated: 12/20/2006
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