Angioplasty with stent placement for heart attack and unstable angina

Treatment Overview

Angioplasty, also know as percutaneous coronary intervention (PCI) or percutaneous transluminal coronary angioplasty (PTCA), is a procedure in which a catheter-guided balloon is used to open a narrowed coronary artery. A stent (a wire-mesh tube that expands to hold the artery open) is usually placed at the narrowed section during angioplasty.

Angioplasty with stent placement has become the first choice of treatment for a heart attack if it can be performed in a timely manner. It is a common procedure in large medical centers.

The goal of this revascularization procedure is to increase blood flow to the heart muscle tissue by clearing out both the blood clot and cholesterol from a ruptured plaque that is blocking the blood vessel. Clot-dissolving drugs (thrombolytics) only remove the blood clot. Angioplasty/stenting is less invasive and has a shorter recovery time than bypass surgery, which requires open-heart surgery.

After you are given a sedative, a thin flexible tube (catheter) is inserted through an artery in the groin or arm and carefully guided up the aorta into the blocked coronary artery. Usually, cardiac catheterization and coronary angiography are performed first to identify any blockages by injecting a dye that contains iodine. The dye makes the coronary arteries visible on a digital X-ray screen. If there is a blockage, the catheter is advanced to the narrowed portion.

In some cases, the doctor might remove loose pieces of clots from the artery. This is done with a small device that is like a vacuum. The doctor moves the device up through the catheter to the blocked artery and removes the clot pieces. This is a newer procedure that can be used during angioplasty.

During the angioplasty procedure, your doctor moves a small balloon up through the catheter to the blocked artery. Then, the balloon at the end of the tube is inflated. The balloon may stay inflated from 20 seconds to 3 minutes, then it is deflated and removed. The pressure from the inflated balloon presses the plaque against the wall of the artery, making more room for blood to flow. See a picture of a balloon angioplasty.

In most cases, a small, expandable wire-mesh stent is permanently inserted into the artery during angioplasty. The balloon is placed inside the stent and inflated, which opens the stent and pushes it into place against the artery wall to keep the narrowed artery open. Because the stent is like woven mesh, the cells lining the blood vessel grow through and around the stent to help secure it. See a picture of stent placement. Your doctor may use a bare metal stent or a drug-eluting stent.

A stent is designed to:

  • Open up the artery and press the plaque against its walls, thereby improving blood flow.
  • Keep the artery open after the balloon is deflated and removed.
  • Seal any tears in the artery wall.
  • Prevent the artery wall from collapsing or closing off again (restenosis).
  • Prevent small pieces of plaque from breaking off, which might cause a heart attack.

View a slideshow on angioplasty for coronary artery disease to see how the procedure is done.

What To Expect After Treatment

After angioplasty, you will be moved to a recovery room or to the coronary care unit. Your heart rate, pulse, and blood pressure will be closely monitored. You will have a large bandage or a compression device at the catheter insertion site to prevent bleeding.

Angioplasty procedures last about 1½ to 2 hours, although preparation and recovery times add to the total time. People usually can start walking within 12 to 24 hours after angioplasty. The average hospital stay is 1 to 2 days for uncomplicated procedures. You may resume exercise and driving after several days.

After angioplasty, you will take antiplatelet medicines to help prevent another heart attack or a stroke. You will probably take aspirin plus another antiplatelet such as clopidogrel (Plavix). If you get a drug-eluting stent, you will probably take both of these medicines for at least one year. If you get a bare metal stent, you will take both medicines for at least one month but maybe up to one year. Then you will likely take daily aspirin long-term. If you have a high risk of bleeding, your doctor may shorten the time you take these medicines.

Why It Is Done

Emergency angioplasty with or without stenting is typically the first choice of treatment for a heart attack.

Although many factors are involved, angioplasty is most often used if you:

  • Are having a heart attack.
  • Have frequent or severe chest pain (angina) that is not responding to medicine.
  • Have evidence of severely reduced blood flow (ischemia) to an area of heart muscle caused by one or more narrowed coronary arteries.
  • Are in good enough health to have the procedure.

Angioplasty may not be a reasonable treatment option when:

  • There is no evidence of reduced blood flow to the heart muscle.
  • Only small areas of the heart are at risk, and you do not have disabling chest pain (angina).
  • You are at risk for having complications or dying during angioplasty due to other health problems.
  • The affected artery cannot be reached during angioplasty.
  • The surgeon or hospital does not have extensive experience in performing these procedures.
  • The hospital does not have access to emergency cardiac surgical facilities.

How Well It Works

Angioplasty relieves chest pain and improves blood flow to the heart. If the artery narrows again, another angioplasty or bypass surgery may be needed.

Angioplasty works well to open a blocked artery after a heart attack. How well it works depends on the type of blockage. But angioplasty can open blocked arteries in about 9 out of 10 people.1

Reclosure (restenosis) of the artery is much less likely to occur after stenting than with angioplasty alone. Stent placement is rapidly becoming the standard procedure during most angioplasty procedures. Drug-eluting stents are coated with medicines that prevent restenosis due to tissue regrowth. These coated stents are even more effective than standard stents in preventing the artery from closing again.

Risks

Risks of angioplasty may include:

  • Bleeding or bruising at the site where the catheter is inserted.
  • Sudden closure of the repaired artery.
  • Heart attack.
  • A need for more procedures. Angioplasty may increase the risk of needing urgent bypass surgery. Also, if the repaired artery narrows again (restenosis), a repeat angioplasty may be needed.
  • Death. The risk of death is higher when more than one artery is involved.

What To Think About

All stents have a risk that scar tissue will form and narrow the artery again. This scar tissue can block blood flow. To help prevent this blockage, drug-eluting stents are coated with drugs that prevent the scar tissue from growing into the artery. Drug-eluting stents may lower the chance that you will need a second procedure (angioplasty or surgery) to open the artery again.

Angioplasty does not require open-chest surgery and has less risk for immediate complications. Long-term outcomes of bypass surgery versus angioplasty are similar. But bypass surgery may be a better option for some people, such as those with diabetes.

Bypass surgery may also be better for people who have extensive coronary atherosclerosis. Also, bypass surgery may be the best option when there are blockages in the coronary arteries that cannot be reached during angioplasty or when angioplasty was tried but did not widen the blood vessel enough.

If you smoke, the benefits of angioplasty are much greater if you quit smoking.

For more information, see bypass surgery versus angioplasty.

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References

Citations

  1. Smith SC Jr, et al. (2006). ACC/AHA/SCAI 2005 guidelines update for percutaneous coronary intervention: Summary article. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Guidelines for Percutaneous Coronary Intervention). Circulation, 113(1): 156–175.

Last Updated: May 5, 2009

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