Angioplasty or balloon angioplasty is a non-surgical, endovascular procedure to widen narrowed or blocked arteries or veins, typically to treat arterial atherosclerosis. An empty, collapsed balloon is passed over a wire into the narrowed locations and then inflated to a fixed size. This expands the vessel and its muscular wall and opens up a blood vessel to improve blood flow.
Angioplasty is a vascular intervention that is typically performed in a minimally invasive or percutaneous method. In addition to ballooning, a stent may also be placed during angioplasty. This procedure is performed in a cath lab by an interventional cardiologist assisted by trained nurses and technicians.
Also called percutaneous coronary intervention (PCI), it is a treatment for narrowed or blocked coronary arteries, which are caused by build-up of cholesterol laden plaques. PCI for stable coronary artery disease reduces chest pain, but does not reduce the risk of death, myocardial infarction or other major cardiovascular events.
This is a procedure where a balloon is used to open up a blood vessel other than the coronary arteries. It is done to treat narrowing due to atherosclerosis of the abdomen, leg or renal arteries. It is done in conjunction with peripheral stenting and atherectomy.
Carotid stenting is done for carotid artery stenosis in patients who are at high-risk for carotid endarterectomy.
Renal artery angioplasty
This is done for atherosclerotic narrowing of renal artery with or without stenting. Renal artery stenosis can cause hypertension and loss of renal function.
This is done for stenosis of the subclavian vein caused by thoracic outlet syndrome.
- When the access vessel (either the femoral or radial artery) is insufficient in size
- Small size, posterior calcification, occlusion, haematoma or a bypass origin all render a vessel unfit for angioplasty access
Preparation for angioplasty
- A history of past and present complaints will be taken.
- Information regarding all medication including herbal etc. will be collected.
- Test for allergy to any medication will be conducted.
- You may be asked to stop aspirin, blood thinners and non-steroidal, anti-inflammatory drugs for a specified time before angioplasty.
- If one is pregnant, the doctor should be informed.
- If you are on blood pressure medications, you will be advised to take them as usual on the morning of the angioplasty with sips of water.
- You may be asked not to eat or drink anything for a few hours before the procedure.
- A nurse or technician will insert an IV line through which sedatives and other medication as required will be given.
- You will be hooked onto a monitor to gauge your heart rate, blood pressure and other vital parameters.
- The areas of your body where the catheter is to be inserted will be shaved, sterilised and covered with a surgical drape.
- Your doctor will numb the area with a local anaesthetic.
- A very tiny skin incision is made.
- Access is usually percutaneous i.e. through the skin. An introducer sheath is inserted into the blood vessel and after injecting a radio-opaque contrast dye is used to guide angled wires and catheters to the region of the body to be treated. To treat the narrowing, a wire is passed through the stenosis and a balloon is passed over the wire and inflated with water mixed with contrast dye. The positioning is verified by fluoroscopy. After the procedure,the balloon, wires and catheter are removed and vessel puncture is sealed.
- Several types of interventional procedures may be used for angioplasty.
- Balloon angioplasty: A specially designed catheter with a small balloon tip is introduced up to the blocked point in the artery and then inflated to compress the plaque and dilates the artery, increasing the blood flow to the heart.
- Stent:a small metal mesh that acts as a scaffold to support the coronary artery. Sometimes a drug eluting stent is used to reduce the risk of re-stenosis. The doctor will determine if this type of stent is appropriate for your type of blockage.
- Rotablation: A special catheter with an acorn shaped, diamond-coated tip is guided to the blockage. The tip spins at a high speed and grinds away the plaque. The debris is washed away in the blood and filtered by the liver and spleen. This is repeated to ensure adequate blood flow. This procedure is rarely used today because balloon angioplasty and stenting have much better results and are technically easier for the cardiologist to perform.
- Atherectomy: The catheter used in this procedure has a hollow cylinder on the tip with an open window on one side and a balloon on the other. When the catheter is inserted into the narrowed artery, the balloon is inflated, pushing the window against the plaque. A blade (cutter) within the cylinder rotates and shaves off any plaque that protruded into the window. The shavings are caught in a chamber within the catheter and removed. This process is repeated as needed to allow for better blood flow. Like rotablation, this procedure is rarely used today.
- Cutting Balloon: The cutting balloon catheter has a special balloon tip with small blades. When the balloon is inflated, the blades are activated. The small blades score the plaque and then the balloon compresses the plaque against the artery wall.
- Much less invasive than bypass surgery
- Lower cost than surgery
- Done under local anaesthesia whereas surgery requires general anaesthesia
- Only a small nick is made and no other surgical incision
- You can return to normal activities much faster after surgery.
Risks and complications
- Tear of the artery
- Heavy bleeding from the site of access
- Embolisation or launching of debris into the blood stream
- Arterial rupture from over-inflation of balloon or use of an inappropriately large or stiff balloon or presence of a calcified vessel
- Haematoma or pseudo-aneurysm formation at the access site
- Rarely, radiation injuries from x-rays used
- A relatively rare complication associated with balloon angioplasty is abrupt vessel closure or occlusion. This happens within 24 hours of the procedure.
- Rarely heart attack and sudden cardiac death
- Infection at the puncture site
- Contrast dye may cause renal failure or a decreased renal function, especially if renal function was already compromised.
Recovery after angioplasty
Post angioplasty, patients will be sent home the next day if there are no complications. The puncture site is checked for bleeding and sheath is removed. Patients will be asked to walk around after 2-6 hours and return to normal, non-strenuous activities in a week. After two weeks, patient can begin low level exercises. A graduated programme with initially performing low and short bouts of exercises and gradually increasing it is advised. All exercise programs should be discussed with your cardiologist.
Patients with stents are usually prescribed aspirin and anti-platelets.
Inform your doctor if you have:
- Swelling, bleeding or pain at the puncture site
- Weakness or feel faint
- Chest pain
- Change in temperature or colour of the limb used for angioplasty
Limitations of angioplasty
- Angioplasty cannot cure or reverse underlying atherosclerosis, which has to be treated by exercise and medications
- Accompanying lifestyle modification such as dietary changes, exercises, stop smoking and limit alcohols are required
- Associated treatment of diabetes and hypertension is needed
- In those who undergo renal angioplasty, in many cases smaller vessels have already been damaged and hence, blood pressure control is limited
- In those with peripheral vascular diseases, stenting is less successful if multiple leg vessels are affected and when small vessels have to be opened. Accompanying smoking cessation, healthy diet and cholesterol control is vital
- In carotid stenting, often a filter device is placed to prevent blood clots and plaques from passing into the brain