How is Coronary Angioplasty done?

Angioplasty procedure

Your heart’s arteries can become blocked or narrowed from a buildup of cholesterol, cells or other substances (plaque). This can reduce blood flow to your heart and cause chest discomfort. Sometimes a blood clot can suddenly form or get worse and completely block blood flow, leading to a heart attack.

Angioplasty opens blocked arteries and restores normal blood flow to your heart muscle. It is not major surgery. It is done by threading a catheter (thin tube) through a small puncture in a leg or arm artery to the heart. The blocked artery is opened by inflating a tiny balloon in it.

Does angioplasty hurt?

• No, angioplasty causes very little pain. The doctor will numb the place where the catheter will be inserted. You may feel some pressure as the
catheter is put in.

• You’ll be awake and alert but may be given medicine to help you relax.

• The place where the catheter was put in may be sore afterwards. Bruising is also common. If you notice any bleeding or increasing pain or swelling, tell your doctor.

People with blockages in their heart arteries may need angioplasty if they are having lots of discomfort in their chest, or if their blockages put them at risk of a heart attack or of dying.

Your doctor will look at a variety of factors to decide if the procedure right for you. These include:

  • Your heart health. The current state of your heart health and if you’ve already had other heart procedures should be considered.
  • The severity of your symptoms. It may be possible to relieve mild symptoms through other means.
  • Your rate of blood flow. Obstruction of 50 percent or more in the left main coronary artery or 70 percent or more in a major epicardial (a vessel lying on the heart) or branch vessel is considered to be significant. Blood flow is measured with non-invasive testing.
  • The presence of high-risk conditions. Certain conditions can complicate the procedure or affect the treatment decision.
  • Your medications. The type and dosage of any medications you may be taking should be considered.
  • The location of the blockage. Your doctor will use angiography, an imaging test, to see which parts of your vascular system are affected and to what extent. Different areas may need to be treated differently.

Anand Gnanaraj, Interventional Cardiologist, Apollo Speciality Hospitals, Vanagaram, Chennai.

For you to understand this I need to go through the history of the treatment for coronary artery disease (blocked arteries supplying the heart) and come to the current scenario.

In the early 70s, if a person had a blocked artery supplying the heart, he had only one option, which was medical treatment. This just controlled the symptoms arising from the disease. It did very little to treat the primary problem. There simply was no definitive treatment for Coronary Artery Disease.

By the 70s, bypass surgery had become popular as a treatment modality for this problem. But then, the mortality (probability of dying during or after surgery) was around 5% or more. So it was concluded that if the patient had only one blocked artery, the risk of surgery outweighs the risk of having the problem and hence treating it medically was the option. Surgery was confined to severe multiple blocks which posed a higher mortality than the bypass surgery itself.

As years passed, the risk of surgery decreased to 2-5% in the eighties. At this time, angioplasty was in its infancy. The way it was done was by using a balloon to dilate the blocked segment. This gave good short term results. But it had a probability of blocking again, which was about 35% – 40%. Again, it was limited to 1 block because the probability would increase with more blocks treated with balloon only. So, bypass surgery continued to dominate the treatment for multiple blocks and severe blocks.

By the late nineties, stents were introduced into interventional cardiology which changed the face of treatment for coronary artery disease. These stents were made of stainless steel and had no special drugs coated on them (hence called Bare Metal Stent – BMS). With the introduction of stents, the probability of blocks reappearing (called restenosis) in an artery treated with angioplasty and stent came down to 25%. This made angioplasty feasible for more people with more severe disease. Also, the surgical mortality had come down to around 2-3%. At this point, both options were equally effective for simple blocks, even if there were more than one block. One problem still remained. Patients who had diabetes had higher probability of the stents blocking again (restenosis). Based on this fact, surgery was still a better option for patients with diabetes, especially for those with multiple blocks.
By 2005, the new generation of stents called Drug Eluting Stents (DES) were available for clinical use. These stents were coated with special drugs that prevented the blocks from developing inside the stent. This drastically changed the treatment for blocked arteries. The restenosis rate came down to 3-5%. At this point the long term results (at the end of 10 years after the index procedure) of surgery or angioplasty were the same, irrespective of the number of blocks and the presence of diabetes. Now the challenge was more of the ability to perform the angioplasty perfectly and give excellent results on the table, which translates to better long term results, than the limitations of the stents, wires, catheters and imaging technologies.

Moreover newer techniques combined with advanced coronary hardware helped cardiologists open 100% blocked arteries. For the last decade, more and more 100% blocks, that were considered impossible to open by angioplasty, are opened using special techniques that are taught to the world by the Japanese cardiologists. Japanese cardiologist have mastered this technique since the Japanese people are unwilling to undergo bypass surgery, based on their belief that their soul will depart, if the chest is opened during bypass surgery. This has forced the Japanese cardiologists to develop better techniques and skill to perform these angioplasties.  The newer retrograde technique has revolutionised the art of doing angioplasty for 100% blocks (called Chronic Total Occlusion- CTO).

The other holy grail of interventional cardiology was the Left Main Coronary Artery (LMCA) disease. People with blocks in Left main artery were considered only for bypass surgery a decade ago. Today angioplasty can treat most of these left main artery disease. There are large scale trials (SYNTAX trial) supporting these treatment modalities. Again, the key here is the ability of the performing cardiologist to give a perfect procedural result. The skill of doing the procedure to perfection is not something that every cardiologist possess. This skill is a combination of clear understanding of the anatomy, very objective thinking, good infrastructure and of course, a gifted pair of hands.

As of today, there are very few patients who cannot be treated with angioplasty. The inability to do angioplasty for some of the patients who are advised bypass surgery is predominantly a combination of the complex anatomy of the blocks, the presence of severe calcium deposition and the lack of experience for operating cardiologist.

Surgical mortality is between 1-2% today, mortality from angioplasty is very low, at 0.5 – 0.7%. This makes angioplasty the procedure of choice for most patients with Coronary Artery Disease. The concept of living with one block because ‘it’s just one blocked artery’ is no longer acceptable since the risk of angioplasty is significantly low.

To conclude, I believe that most patients should be offered coronary angioplasty with the newer stents and the ones who cannot have good results with angioplasty, even under skilled hands, should be offered bypass surgery.

Bypass or angioplasty with stenting: How do you choose?

Angioplasty is often used when there is less severe narrowing or blockage in your arteries and when the blockage can be reached during the procedure.

CABG might be chosen if you have severe heart disease, multiple arteries that are blocked, or if you have diabetes or heart failure.

Bypass or angioplasty with stenting: How do you choose?

It’s your doctor’s call, but it’s good to understand, and to weigh, your options.

Your heart doesn’t just pump blood—it needs blood to survive. So when blocked coronary arteries threaten the heart’s blood supply, something must be done.

There are two main approaches.

Angioplasty plus stenting. A small balloon wrapped in a collapsed wire mesh stent is inserted into a blood vessel in the groin or arm and maneuvered into the heart. When the balloon is inflated, it flattens the cholesterol-filled plaque that has been restricting blood flow through the artery. When the balloon is deflated and removed, the stent remains behind to prop open the artery. This is called balloon angioplasty with stenting.

Coronary artery bypass graft (CABG). During open-heart surgery, an artery or vein taken from elsewhere in the body is stitched in place to reroute blood around the blocked artery.

Which is best? It’s not a tossup. But the right choice depends on a number of factors, says Harvard revascularization expert Dr. Donald E. Cutlip, a surgeon at Beth Israel Deaconess Medical Center.

The Choice Between Heart Bypass Surgery and Angioplasty

CABG is more invasive, but repeat procedures are more likely with stenting.

Coronary angioplasty is used to restore blood flow to the heart when the coronary arteries have become narrowed or blocked due to coronary artery disease (CAD).

your doctor will talk to you about Two  treatment options.

These options include angioplasty and coronary artery bypass grafting (CABG), a type of open-heart surgery.

Your doctor will take into account a number of factors when recommending the best procedure for you.

These factors include how severe your blockages are, where they’re located, and other diseases you may have.

Angioplasty is often used when there is less severe narrowing or blockage in your arteries and when the blockage can be reached during the procedure.

CABG might be chosen if you have severe heart disease, multiple arteries that are blocked, or if you have diabetes or heart failure.

Compared with CABG, some advantages of angioplasty are that it:

  • Has fewer risks than CABG
  • Isn’t surgery, so it won’t require a large cut
  • Is done with medicines that numb you and help you relax. Unlike CABG, you won’t be put to sleep for a short time
  • Has a shorter recovery time

Angioplasty also is used as an emergency procedure during a heart attack. As plaque builds up in the coronary arteries, it can burst, causing a blood clot to form on its surface. If the clot becomes large enough, it can mostly or completely block blood flow to part of the heart muscle.

Quickly opening a blockage lessens the damage to the heart during a heart attack and restores blood flow to the heart muscle. Angioplasty can quickly open the artery and is the best approach during a heart attack.

A disadvantage of angioplasty as compared with CABG is that the artery may narrow again over time. The chance of this happening is lower when stents are used, especially medicine-coated stents. However, these stents aren’t without risk. In some cases, blood clots can form in the medicine-coated stents and cause a heart attack.

Your doctor will discuss with you the treatment options and which procedure is best for you.

Fasting (not eating or drinking) before the procedure.

Even though angioplasty takes one to two hours, you will likely need to stay in the hospital overnight.

What to Expect Before Coronary Angioplasty

Meeting With Your Doctor

If your angioplasty isn’t done as emergency treatment, you’ll meet with your doctor before the procedure. Your doctor will go over your medical history (including the medicines you take), do a physical exam and talk about the procedure with you. Your doctor also will order some routine tests, including:

  • Blood tests
  • An EKG (electrocardiogram)
  • A chest x-ray

When the procedure is scheduled, you will be advised:

  • When to begin fasting (not eating or drinking) before the procedure. Often you have to stop eating or drinking by midnight the night before the procedure.
  • What medicines you should and shouldn’t take on the day of the angioplasty.
  • When to arrive at the hospital and where to go.

Even though angioplasty takes one to two hours, you will likely need to stay in the hospital overnight. In some cases, you will need to stay in the hospital longer. Your doctor may advise you not to drive for a certain amount of time after the procedure, so you may have to arrange for a ride home.

Preparation

In the cath lab, you will lie on a table.

An intravenous (IV) line will be placed in your arm to give you fluids and medicines.

The medicines will relax you and prevent blood clots from forming. These medicines may make you feel sleepy or as though you’re floating or numb.

To prepare for the procedure:

  • The area where the catheter will be inserted, usually the arm or groin (upper thigh), will be shaved.
  • The shaved area will be cleaned to make it germ-free and then numbed. The numbing medicine may sting as it’s going in.

A video showing the preparations for coronary angioplasty.

  • Before the angioplasty, your doctor will assess your medical history and do a physical exam.
  • You will also have an imaging test called a Coronary Angiogram to see if your blockages can be treated with angioplasty. A Coronary Angiogram helps doctors determine if the arteries to your heart are narrowed or blocked. In a Coronary Angiogram, liquid dye is injected into the arteries of your heart through a catheter – a long, thin tube that is fed through an artery from your groin, arm or wrist right up to arteries in your heart. As the dye enters your arteries, they become visible on X-ray and video, so your doctor can see where your arteries are blocked. If your doctor finds a blockage during your Coronary Angiogram, it is possible that he or she may decide to perform angioplasty and stenting immediately after the angiogram, while your heart is still catheterized.
  • Usually, you will need to stop eating or drinking six to eight hours before the procedure is scheduled. Your preparation may be different if you’re already staying at the hospital before your procedure.
  • You will also have some routine tests first, including a chest X-ray, electrocardiogram and blood tests.
  • Follow your doctor’s advice about regulating your current medications before angioplasty. Your doctor may instruct you to stop taking certain medications before angioplasty.
  • Do inform your doctor about allergies as well as previous allergic reactions to dyes used in diagnostic investigations.
angioplasty procedure 1

How is Coronary Angioplasty done?

A very thin wire is threaded through the catheter and across the blockage.

Over this wire, a catheter with a thin, expandable balloon on the end is passed to the blockage.

The balloon is inflated. It pushes plaque to the side and stretches the artery open, so blood can flow more easily.

How is Coronary Angioplasty done?

A video showing the process of  Coronary Angioplasty ?

How is Coronary Angioplasty done?

1. A doctor numbs a spot on your groin or arm and inserts a small tube (catheter) into an artery.

2. The catheter is threaded through the arterial system until it gets into a coronary (heart) artery.

3. Watching on a special X-ray screen, the doctor moves the catheter into the artery. Next, a very thin wire is threaded through the catheter and across the blockage. Over this wire, a catheter with a thin, expandable
balloon on the end is passed to the blockage.

4. The balloon is inflated. It pushes plaque to the side and stretches the artery open, so blood can flow more easily. This may be done more than once.

5. In many patients a collapsed wire mesh tube (stent) mounted on a special balloon, is moved over the wire to the blocked area.

6. As the balloon is inflated, it opens the stent against the artery walls. The stent locks in this position and helps keep the artery open.

7. The balloon and catheters are taken out. Now the artery has been opened, and your heart will get the blood it needs.

Steps in Angioplast

When you’re comfortable, the doctor will begin the procedure. You will be awake but sleepy.

A small cut is made in your arm or groin into which a tube called a sheath is put. The doctor then threads a very thin guide wire through the artery in your arm or groin toward the area of the coronary artery that’s blocked.

Your doctor puts a long, thin, flexible tube called a catheter through the sheath and slides it over the guide wire and up to the heart. Your doctor moves the catheter into the coronary artery to the blockage. He or she takes out the guide wire once the catheter is in the right spot.

A small amount of dye may be injected through the catheter into the bloodstream to help show the blockage on x-ray. This x-ray picture of the heart is called an angiogram.

Next, your doctor slides a tube with a small deflated balloon inside it through the catheter and into the coronary artery where the blockage is.

When the tube reaches the blockage, the balloon is inflated. The balloon pushes the plaque against the wall of the artery and widens it. This helps to increase the flow of blood to the heart.

The balloon is then deflated. Sometimes the balloon is inflated and deflated more than once to widen the artery. Afterward, the balloon and tube are removed.

In some cases, plaque is removed during angioplasty. A catheter with a rotating shaver on its tip is inserted into the artery to cut away hard plaque. Lasers also may be used to dissolve or break up the plaque.

If your doctor needs to put a stent (small mesh tube) in your artery, another tube with a balloon will be threaded through your artery. A stent is wrapped around the balloon. Your doctor will inflate the balloon, which will cause the stent to expand against the wall of the artery. The balloon is then deflated and pulled out of the artery with the tube. The stent stays in the artery.

After the angioplasty is done, your doctor pulls back the catheter and removes it and the sheath. The hole in the artery is either sealed with a special device, or pressure is put on it until the blood vessel seals.

During angioplasty, strong antiplatelet medicines are given through the IV to prevent blood clots from forming in the artery or on the stent. These medicines help thin your blood. They’re usually started just before the angioplasty and may continue for 12-24 hours afterward.

Coon concerns about Coronary Angioplasty.

Robert Rister, Author of Minimal Medication, available on Kindle Unlimited

in reply to the question “Does angioplasty clear all heart blockage? Can a person with 95% heart blockage live a normal life after angioplasty?”.

Can someone lead a normal life after a 95% blockage of an artery? I’m not a doctor and I’m not offering medical advice, but I can speak from personal experience: Yes, but it’s important to know what’s going on in treatment. Angioplasty can open up an artery, but it’s almost always followed with a stent. For the lining of the artery to accept the stent, so it grows into place, so blood clots can’t from around it, it’s utterly essential to take all your prescribed anticoagulants (blood thinners). If you are diabetic, you also have to keep your blood sugar levels under control, and you have to watch blood pressure and cholesterol. All of this isn’t that hard to do, but you do have to do it. That being said, you will probably feel a lot better after treatment and you will go back to living the normal life you had forgotten. There are lots of things that can go wrong, there are lots of variations in treatment, but, yes, many people do live normal lives after angioplasty, stents, and bypass. Most feel tremendously better.

Liang-Hai Sie, Retired general internist, former intensive care physician.

in reply to the question “Does angioplasty clear all heart blockage? Can a person with 95% heart blockage live a normal life after angioplasty?”.

Does angioplasty clear all heart blockage? Can a person with 95% heart blockage live a normal life after angioplasty?

If successful, they will perform an angioplasty to open up the coronary, and after that using the same sheath put in a stent to keep the dilated coronary open.
After that, the usual anti platelet meds usually low dose aspirin combined with Plavix® or something like that for a year, high dose statin, optimalizing blood pressure (and if diabetic diabetes) control, and most of all: NO SMOKING.

Our fifty something neighbor, a heavy smoker, underwent a successful angioplasty and stent placement because of serious angina pectoris, stopped smoking, but felt so well that he started smoking again so after a few month literally dropped dead at home.  If someone keeps smoking docs can’t make that right.

Remember the coronary vessel “repaired” isn’t they only vessel damaged by whatever had damaged the target to be treated vessel, so those later on could also cause problems.

How to Exercise Safely After Angioplasty?

Exercising after this procedure is generally an important part of your long-term recovery. Be safe and smart when it comes to the type, amount, and intensity of the exercise you choose. That way, you can allow your body to heal and work to prevent further cardiac issues.

What’s Life After Stent Placement?

Recovery and Return to Normal Activities

Patients who undergo non-emergency treatment will likely stay in the hospital overnight to be monitored. They may be able to return to light, routine activities during the first few days after the procedure. Bruising or discoloration may occur at the catheter insertion site, as well as soreness when pressure is applied, and patients can expect to feel more tired than usual for a few days. Patients should drink plenty of fluids to help flush out any contrast dye.

About a week after the procedure, the doctor may say it’s okay to return to more moderate activities, and work, but avoid any activities that cause shortness of breath or chest pain. About three to four weeks after the procedure, it may be safe to resume strenuous physical activity and lifting heavy objects; patients must receive clearance from their doctor.

For some patients, their doctor may also recommend lifestyle changes. This could include exercise, quitting smoking, and following a healthy diet.

Patients who undergo stent placement following a heart attack may have a different recovery. Their hospital length of stay and return to activities will likely be longer.

During the recovery period, patients should seek medical attention if they experience any of the following:

  • Bleeding, swelling, pain, or discomfort at the catheter insertion site
  • Redness, swelling, drainage, or fever indicative of infection
  • Changes in temperature or color in arm or leg where the procedure was performed
  • Faintness or weakness
  • Chest pain
  • Shortness of breath

Patients may be encouraged to attend at least one follow-up appointment to make sure the catheter insertion site is healing properly. A stress test may also be performed several weeks after the procedure, which will help the doctor determine appropriate activity and exercise recommendations.

Depending on the stent used, patients may have to be monitored to ensure the stent is working properly and is in the right place. Airway stents may be checked through bronchoscopy several weeks after the procedure; a chest X-ray or CT scan could also be used. A CT angiograph or ultrasound may be performed to check a stent graft is not leaking several weeks following placement, and possibly for the long-term. If leaking or another issue occurs, the stent may need to be continuously monitored, and if the leak is severe, surgical intervention may be necessary.

Medications to Take

After the procedure, it is important to adhere to the doctor’s recommended treatment because this could help prevent blood clots that may re-block the artery. One way to prevent this is through antiplatelet medication, including aspirin and a P2Y12 inhibitor. Which P2Y12 inhibitor a patient is prescribed—clopidogrel, prasugrel, or ticagrelor—is individualized for each patient. Some patients will undergo dual antiplatelet therapy (DAPT), a combination of aspirin and a P2Y12 inhibitor. Treatment duration will depend on a patient’s cardiac history, their bleeding risk, and whether they received a drug-eluting stent (DES) or a bare metal stent (BMS).

Gejinder Singh, Nutirtion and Wellness Advisor

For coronary angioplasties, hospitals in India generally provide treatment cost in the form of packages. A package includes the overall cost including surgeon’s fee, taxes, accommodation & nursing, medications and investigative checkups plus the cost for pre-operative checkups like ECG, EKG, CT Scan, etc and the doctor’s consultation fee for post-operative visits.

The estimated Coronary Angioplasty Cost in India using single stent comes out to be in the range of INR 2 to 3 lacs. In this, the angioplasty costs nearly INR 1 to 1.5 lacs.

However, the below mentioned factors play a huge role in determining the overall cost.

1. Metro City or Small City 
The cost of angioplasty varies with the city too. For example, angioplasty costs approximately INR 1.9 lacs in Mumbai while in Nagpur, it is INR 1.4 lacs and so on.

2. Type of Stent Used
The cost of overall surgery depends on the medical condition of the patient and the type of stent used in the same. For example, it makes a huge difference whether a bare metal stent is employed, a drug-eluting stent (DES) or a bioresorbable one. Till early 2017, the three kinds of stents amounted to INR 20,000-40,000, INR 24000-1,50,000 and INR 1,70,000-2,00,000 respectively. However, with recent dip in prices by the National Pharmaceutical Pricing Authority, a bare metal stent will now amount to INR 7,500 and a DES to INR 30,000 resulting in a decreased overall package cost.

Rachel Smith, Masters Medicine and Healthcare & Visiting and Travel

The mentioned range of Cost of Angioplasty in India may vary depending on many factors:

  • Type of the technology used
  • Overall health of the patient
  • Expertise of the specialist
  • Type of the Hospital
  • Current age of the patient
  • Types of treatment & medications provided

Media reports on cost of Coronary Angioplasty.

Angioplasty cost falls up to 18 per cent on stent price cap

Angioplasty cost at corporate hospital chains came down by 8-12% to ₹2.05 lakh-2.20 lakh from ₹2.10 lakh-2.20 lakh, the study showed.

Stents cheaper, but not all get benefit

Highlights

Before price cap, the cost was prohibitive for more than two and so people often opted for open heart as it worked out to cheaper than angioplasty.

But now, multi-stenting is affordable and many patients  who would have been forced to go in for an open heart surgery, now opt for stenting.

cost of coronary angioplasty.

Narayana Health to hike prices of angioplasty procedures as 6-month embargo ends

Dr Ashutosh Raghuvanshi, Vice Chairman, MD and Group CEO at Narayana Health said that prices caps on stents brought down the angioplasty cost by 10-12%.

Cheaper angioplasty still a distant dream as hospitals raise procedure rates

Price cap on stents fails to bring down angioplasty costs considerably; Many hospitals hike procedure rates to make up for the loss of margins

Chirantan Mangukia, Consultant Cardiovascular Surgeon at Wockhardt Hospitals (2016-present)

Angioplasty with stent has better angina relief compared to balloon angioplasty or medications in certain disease configurations.

Patients are relieved of angina with stent, but they don’t get any survival benefit. Only remedy for increasing survival in chronic stable angina patients is – Coronary artery bypass.

But yes, in acute myocardial ischemia, stents are life saving.

Jaydeep Desai, works at Interventional Cardiology

Angioplasty with only balloon ( something which is not practiced routinely in this era ) has a recurrence rate of 30–50% ( higher recurrence in diabetics) .

Angioplasty with Stenting , preferably with Medicated stents(DES) carries a recurrence rate of 5–8% with current generation of stents . Angioplasty has survival advantage over bypass in all Acute situations wherein CABG is too high risk at that moment .

Only medical therapy ( optimum and well titrated) has its own place for Chronic Stable Angina , however , one needs intervention if there is worsening of symptoms despite medical therapy .

Scientific reports on the survival of patients who had Coronary Angioplasty.

Five years after the procedures, 90.7% of the bypass patients and 89.7% of the angioplasty patients were still alive,

says Mark A. Hlatky, MD, senior author of the analysis and a professor of health research and policy and professor of medicine at Stanford University School of Medicine in Palo Alto.

Exercising after this procedure is generally an important part of your long-term recovery. Be safe and smart when it comes to the type, amount, and intensity of the exercise you choose. That way, you can allow your body to heal and work to prevent further cardiac issues.

Best hospitals for Coronary Angioplasty