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Angioplasty is a medical procedure that is done to treat coronary artery disease (CAD). Here a special tube called catheter is used to enter inside the blocked or narrowed coronary artery which is then opened by means of inflating a tiny balloon within the vessel.
In many cases, a metal mesh tube called a stent is also placed after removing the blockage. This is done to keep the artery expanded. This is termed as angioplasty and stenting.
Nowadays, certain medicine containing stents are also used which are considered to prevent the arteries from getting blocked again.
This is a minimally invasive procedure where a small cut is made on a blood vessel of the leg or arm, through which fine tools are passed into the blocked coronary arteries of the heart.
The other procedure to treat CHD is a more crude surgical method, called coronary artery bypass grafting (CABG) where typically the chest is cut open to access the heart and its blood vessels.
It is estimated that more than 3 crore people in India have coronary heart disease. In the last four decades, the prevalence of CHD has increased to 4 times.
It is more common in the urban population where it is said to affect about 1 in 10 people.
There is also an increase in the number of deaths due to CHD. It is estimated to cause death in about 1/4th (23%) of the patients.
It was calculated that about 70,000 people underwent angioplasties in 2007, of which 73% used a drug containing stent. This has become significantly higher over the years, where in 2017, it was estimated that 3.87 lakhs angioplasties were done and 5.11 lakhs stents were put. Amongst them, about 97% of stents were drug containing stents.
An angioplasty package costs anywhere between Rs 1 and 3 lakh depending upon the hospital, number of stents and type of stent, facility, type of room, and the location.
Capping off the stent prices by the NPPA has brought about a 10-12% fall in the price of the angioplasty procedure.
The survival rate after the angioplasty has been found to be very high, 98.9%. The survival rate after CABG has also been found to be around same, 98.2%
The long term survival rate of these patients after 5 years of both the procedures has also been found to be high, around 90%.
Angioplasty may be used in the following cases:
Heart attack: blockage leading to a heart attack. This can be done as an emergency procedure to reduce damage to the heart.
Angina: blockage leading to chest pain (angina) which is worsening and not controlled by medicines.
Heart failure: blockage leading to poor functioning of the heart.
Angioplasty and stent placement provides faster and easier recovery, but can’t be done in all patients with CAD.
Know which patients need CABG
Know how to choose- Angioplasty vs CABG
The angioplasty is a minimally invasive procedure done by a cardiologist (heart specialist). The procedure is done in a cardiac catheterization laboratory or ‘Cath lab’ using a fluoroscopy machine (Xray machine), contrast dye, catheter, balloon catheter, and stents.
• Sedation: Angioplasty doesn’t require general anesthesia. The person remains awake during the entire procedure but is relaxed by using sedatives and pain killers.
• Blood-thinning medicines and fluids are also given through the IV line.
• Preparation of catheter insertion: An area is made sterile using an antiseptic solution in the groin, wrist, or arm. The anesthetic medicine is injected to numb the area where a small cut is made to allow the insertion of the catheter.
• Catheter guidance and angiography: A special flexible tube called a catheter is inserted from the prepared site into the artery. With the help of X-ray images, the catheter is carefully guided up to the coronary arteries. The X-ray dye is then injected into the coronary arteries to visualize the arteries and their blockage.
• Angioplasty: after locating the blockage site, a guidewire is passed across the blockage. Then, a balloon catheter is guided over the wire into the blockage site. The balloon is then inflated to compress and crush the blockage/plaque and open up the vessel, restoring the blood flow.
• Stenting: a metal wire mesh, called a stent, usually coated with a drug (DES) is inserted along the balloon catheter at the site of the blockage. The stent expands when the balloon is inflated and remains at the site permanently, keeping the vessel expanded. DES contains drugs that may lower the chances of artery restenosis.
Before completing the procedure check angiography is done to confirm a good flow of dye within the coronary artery. The procedure may take a few hours depending on the number of blockages, difficulty level, and presence of any complications.
Many times angioplasty is done as an emergency procedure where the patient presents with a heart attack or acute coronary syndrome. These patients are immediately taken to the Cath lab for angiography and angioplasty. Before this, they are quickly evaluated on the basis of clinical symptoms and some tests such as blood reports, chest X-ray, and ECG.
In non-emergency condition, there are some instructions that need to be followed in order to prepare yourself for the procedure:
• Tell your doctor about the medicines, supplements, or any ayurvedic or homeopathic medicine you’re taking.
• The doctor may ask you to stop or change the dose of medicine like aspirin, NSAIDs, and others.
• Tell the doctor about any health condition or illness you have.
• Inform your doctor if you think you might be pregnant.
• Don’t eat or drink for 8 hours before the test. The medicine can be taken with a small sip of water if asked by the doctor.
• Tell your provider if you are allergic to contrast material or iodine.
Before the procedure, the doctor would give some pain killers, blood thinners and numbing medicine at the catheter site and sedative to relax the body.
Usually, the patient stays in the hospital for 1 or two days. Generally, a person can start to walk with 6 to 7 hours hours after an uncomplicated procedure. This depends upon the general condition of the patient, where the catheter was inserted, the indication of the angioplasty, and the associated conditions.
Complete recovery may take a several days to a weeks time.
Know more about how to care for yourself after angioplasty.
In most people, angioplasty and stenting gives good results and significantly improves the blood across the previously narrowed or blocked artery. However, it doesn’t treat the cause of CAD or the risk of developing stenosis again.
To prevent this, the patient needs to continue with taking the prescribed medicine and follow a healthy lifestyle as follows:
• Blood thinners (anti-platelet drugs): blood-thinning medicines such as aspirin, clopidogrel, and others, play a very important role after angioplasty. Most of the people need to take aspirin throughout their life. Clopidogrel is usually given after stenting for about 6 months to 1 year.
• Medicines to control cholesterol or BP.
• Eat a heart-healthy diet, such as low saturated fat and low sodium diet
• Exercise regularly
• Maintain lower cholesterol levels
• Maintain healthy body weight
• Keep good control over other associated conditions like BP or diabetes.
• Quit smoking if you smoke
• Avoid stress and do relaxation exercises like yoga, breathing exercises, and others.
Angioplasty and stenting is a minimally invasive procedure that is generally safe. However, like any other procedure it is also associated with a small risk of developing some complications:
The important risks associated with angioplasty are:
It is a development of narrowing or blockage again at the treated coronary artery site usually between 1- 6 months after angioplasty. Patients usually, present with the development of chest pain on exertion (exertional angina), when the lumen of the artery gets blocked by more than 50%. Some people about 5-10% may present with a heart attack.
Risk factors for developing restenosis are as follows:
• Reduced renal function
• Small vessel of size less than 2.5mm
• Long lesion of more than 40mm.
The risk of developing restenosis with only angioplasty and stenting is about 40-50%, whereas with metal stent placement is about 16-32%. The chances of developing restenosis are least with Drug eluding stents (DES), which is about 5-10% which is the reason why almost all stents used nowadays are DES. The rate of restenosis with DES depends on the type of DES used (1st or 2nd generation stent), stent length, stent size, shape of the lesion, presence of diabetes.
Know more about restenosis
Formation of the clot is another problem that can occur at the site of the implanted stent. This is considered different from restenosis, as this tends to be a more serious life-threatening complication which generally leads to sudden and complete blockage of the artery.
The thrombosis occurs usually within one month and is very less after that. With newer techniques, the chances of development of thrombosis are very low, with 0.7% occurring in one year and 0.2 to 0.6% occurring after that.
High-pressure balloon angioplasty and prescription of two anti-platelet drugs like aspirin with clopidogrel are used to lower chances of clot formation.
Some people may have bleeding from the catheter insertion site in the arm or leg. Usually, this is minimal but sometimes it can become troublesome leading to loss of a significant quantity of blood. These patients may need a blood transfusion, compression, or surgical procedure.
• Kidney damage– this may occur especially in people with pre-existing kidney damage and sometimes may lead to kidney failure in these patients.
• Irregular heartbeat
• Stroke– is very rare and may occur due to the displacement of clots from the aorta.
• Allergic reaction to the material or drug used in the stent material- very rare
• Allergic reaction to the dye used for angiography- very rare
The warning signs could indicate underlying complication which could be life-threatening and thus indicates a need for immediate medical help:
1. Chest pain or shortness of breath: this could be similar or different from the previous episode of heart attack or angina. This could suggest the development of restenosis or thrombosis within the stent.
2. Bleeding from the catheter site insertion.
3. Pain, swelling, and discoloration at the site of catheter insertion: this may suggest bleeding or clot formation at the insertion site.
4. Change in color and temperature of the limb from where the catheter was inserted- could suggest blocked blood supply.
5. Fever, pain, or drainage from catheter site may indicate infection.
6. Development of facial deviation, limb weakness, or slurring of speech may indicate a stroke.
7. Fatigue or dizziness
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