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About Coronary Angioplasty

The heart receives blood via a set of arteries known as the coronary arteries. Healthy arteries are flexible, strong and elastic and have a smooth inner lining that allows blood to flow freely. These arteries can become stiff and narrow if cholesterol, cells and other substances build up inside the arteries. This build up can cause a partial or total blockage in the artery, restricting blood flow which in turn can restrict vital oxygen and nutrients.

A reduced flow of blood to the heart can cause various symptoms. Chest discomfort is the most common symptom. This is call angina. Both a partial and completely blocked artery can lead to a heart attack.

Treatment of angina may be by one of three means:

  1. Medications to improve blood supply through the narrowed arteries;
  2. Coronary artery bypass surgery;
  3. Percutaneous transluminal coronary angioplasty.

Coronary Angioplasty is an invasive procedure performed to reduce or eliminate blockages in the coronary arteries, restoring blood flow to the heart tissue that has been deprived of oxygen and nutrients.

Coronary Angioplasty is not suitable for all blocked or narrow coronary arteries. Factors such as the number of blockages and where they are situated will determine if angioplasty is the most suitable treatment option for you. Your cardiologist will have determined the most suitable treatment based partly on the result of the Coronary Angiography.

Pre-operative Preparation

Fasting

You will be asked to fast for 4 hours prior to the procedure, this includes food and water, although if you need to take medications you will be able to have a small amount of water.

Medication Instruction

Your cardiologist will advise if there is to be any changes to your usual medications prior to the procedure. If you are on Warfarin, you will usually be asked to cease taking this for 3-4 days prior, but you will need to check this with your Cardiologist. DO NOT stop taking Aspirin or Plavix / Iscover. Take other medication as usual on the day with a small amount of water. If you are unsure of any of the above, please check with your doctor.

Allergies

Please advise the staff if you are aware of any allergies you may have. X-ray dye (contrast solution) used in in this procedure contains Iodine. If you have an allergy to Iodine, you must inform your doctor prior to this procedure.

Premedication

A small plastic tube called an Intravenous Cannula will be inserted into a vein in your arm and an intravenous drip will be connected to it.

You may be given a mild sedative prior to the procedure to help you relax.

Skin Preparation

Your right groin area or right radial area on your arm will be clipped and you will be asked to shower using an antiseptic soap and dress in a hospital gown.

Tests

Your doctor may request you to have some tests done prior to the procedure when you arrive in hospital. These may include blood tests, 12 lead Electrocardiograph (ECG) and/or a chest X-ray. Bring with you any chest X-rays you may have had from the last 6 months.

Duration

Depending on how many blockages you have will depend on the length of the procedure, your procedure will most likely take between 40 minutes to 1 ½ hours.

Procedure

The procedure is performed in a special theatre called the Cardiac Catheter Laboratory. This theatre has X-ray equipment and monitors to assist in acquiring pictures of the coronary arteries.

Monitoring

Electrodes are attached to your arms, chest, legs and back to monitor your heart rhythm. Your Blood pressure and oxygen saturation will also be monitored throughout the procedure.

Anaesthetic

General anaesthetic in NOT required for this procedure, so you are awake for the duration. You may be given additional medications for sedation or pain relief during the procedure through the intravenous drip connected to the small tube in your arm.

Arterial Puncture

Access to the blood circulation may be from the right or left leg, right elbow or right wrist artery. A small amount of a local anaesthetic agent (usually 1% Lignocaine) is injected into the skin. You may briefly experience a cool or a mild stinging sensation.

A hollow needle is inserted into the artery and a small tube (6cm to 9cm in length) called a "sheath" is inserted so as to gain access to the circulator system. You may feel a bit of pressure while the sheath is being inserted. Thereafter you should not feel any discomfort.

A long, thin plastic tube called a "catheter" is inserted into the sheath and advanced through the arterial system into a coronary artery. You won't feel the catheter in your body.

By watching on a special X-ray screen, the cardiologist can move the catheter into the artery. A small amount of contrast dye is injected through the catheter. Areas of blockage are shown up on the X-ray images, so your cardiologist knows precisely where to target treatment.

Next, a very thin wire is threaded into the narrowed artery across the blockage. Over this wire, a thin, expandable balloon is passed to the blockage. The balloon is inflated at the site, partially decreasing the amount of blockage. The balloon then deflates.

Because the balloon temporarily blocks blood flow to part of your heart, it is common to experience chest discomfort / pain while it is inflated. Your cardiologist might inflate and deflate the balloon several times before it is removed, stretching the artery a bit more each time to widen it. If you have several blockages, the procedure may be repeated at each site.

Your cardiologist and a team of cardiac nursing staff will be monitoring you during the procedure. If you are experiencing any discomfort or pain, it is important that you let them know. Your cardiologist will prescribe medication that the nursing staff will administer during the procedure to try and make you as comfortable as possible.

Stent Insertion

Once the artery is widened, a device called a stent may be placed in the artery as scaffolding to help prevent it from re-narrowing after the angioplasty. The stent looks like a very tiny lattice-work coil of wire and mesh. A stent is not deployed in all instances. Your cardiologist will discuss this with you.

To insert a stent, it is compressed onto a balloon catheter and guided to the blockage. When the balloon inflates, 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.

Some stents can be coated with medication (called Drug Eluting Stents) that is slow is slowly released to help prevent arteries from reclogging. If you have a Drug Eluting Stent you will have to remain on your anti-coagulation medications for a minimum of 6 to 12 months. If you need to stop this mediation for other procedures, you will need to check with your Cardiologist before doing so.

Post-operative Care

Your Cardiologist may leave the tube in your groin/arm for several hours after the procedure. If your puncture site is in your groin you will have to lie flat until the sheath is removed this may be 3 to 6 hours.

Alternatively, you doctor may choose to remove the sheath and use other measures to close the artery such as plugging them with collagen. In any case, you may have bruising and tenderness at the point where the sheath was removed.

You will remain in hospital overnight for monitoring of your vital signs and also you puncture site.

Discharge

Your cardiologist will see you the next day before you are discharged and will answer any questions you or your family may have. They will also discuss any changes to your medications.

Your cardiologist will also schedule a follow-up appointment with you one to three months after your procedure.

Before leaving hospital, you will receive information about long-term therapy that may assist in preventing further coronary artery disease and instructions regarding when to return to work.

Heavy lifting and vigorous exercise should be avoided for several days to ensure that the arteries are properly healed. Most patients return to work or their normal routine the week after their coronary angioplasty.

It is normal to have some bruising, a small lump (about the size of a pea) and/or a small amount of pain where the sheath was inserted for the first week after the procedure.

If you are concerned about the amount of bruising and/or pain at your puncture site, you should have this reviewed by your GP or cardiologist.

Other symptoms that warrant urgent medical attention include:

  • If the puncture site starts to bleed or swell
  • If you develop increasing pain or discomfort at the puncture site
  • If you develop signs of infection, such as redness, drainage, or fever
  • If there is change in temperature of colour of the leg or arm that was used for the procedure
  • If you feel faint or weak
  • If you develop chest pain or shortness of breath.

Possible Risks and Complications

The risks of coronary angioplasty depend on:

  • How bad your coronary artery disease is;
  • How well your heart is pumping;
  • How old you are;
  • How healthy your other organs are;
  • If you have had a previous bypass operation.

Your artery can re-narrow within months, requiring further procedures including surgery. Therefore, it is important that you report any recurrent of unusual symptoms you may experience to you doctor.

The below table outlines some of the more serious risks of the procedure.

Major Complications
Heart Attack 1 in 1000
Stroke or Mini-stroke (TIA) 1-2 in 1000
Perforation of large blood vessels or heart 1 in 1000
Urgent open heart surgery 1 in 1000
Urgent balloon angioplasty 1 in 1000
Death 1 in 1000
Blood Vessel Complications
Blood clot 1 in 1000
Major bleeding Less than 1 in 100
Pseudo-aneurysm formation: blood clot with connection to the artery lumen Less than 1 in 100
Need for surgery because of blood vessel complications Less than 1 in 100
Allergic Reaction
Skin reaction Less than 1 in 20
Severe life-threatening reaction requiring resuscitation Less than 1 in 1000
Abnormal Heart Rhythm
May require electrical shock treatment or temporary / permanent pacemaker Less than 1 in 500
Other Risks<
Deterioration in Kidney Function Less than 1 in 100
Infection Less than 1 in 1000
Skin Injury from Radiation Less than 1 in 10,000