ANGIOPLASTY AND STENT PROCEDURE
What is coronary angioplasty and stenting/percutaneous coronary intervention (PCI)?
Coronary angioplasty is a procedure in which a catheter balloon is used to dilate a coronary artery narrowing. A stent (a metal mesh tube that expands to hold the artery open) is usually inserted and dilated to scaffold the narrowed section of the artery.
Angioplasty can usually be performed immediately following a diagnostic coronary angiogram.
Why do I need to have coronary angioplasty and stenting?
Your doctor will recommend angioplasty and stenting if a significant blockage has been identified during a coronary angiogram. A coronary blockage is considered significant if it has a narrowing of 70% or more in the internal diameter of the vessel.
Coronary angioplasty and stent (PCI) procedure involves the passage of catheters into the arteries leading to the heart allowing for injection of xray contrast to image your coronary arteries. If significant narrowing (>70%) is identified, a balloon catheter will be used to dilate the artery prior to stent placement. This will allow the artery to remain open and for adequate blood to be restored to the heart muscle.
Occasionally additional tests such as Fractional Flow Reserve (FFR), Intravascular Ultrasound (IVUS) or Optical Coherence Tomography (OCT) are required to confirm the extent of coronary artery blockage. This procedure may be performed as a planned procedure or in an emergency during a heart attack.
The goal of angioplasty/dilating the artery is to open the narrowed arteries to restore the flow of blood to your heart muscle and minimise damage to your heart.
Your coronary arteries can narrow because of significant build-up of plaque. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. A coronary artery can become blocked suddenly because of a ruptured plaque, resulting in a heart attack. A blood clot may need to be aspirated out of the artery or hard calcified plaque may need to be drilled prior to stent placement. Angioplasty and stenting will press the plaque against the artery wall and restore blood flow to the heart muscle.
This procedure has the same preparation as for coronary angiography.
Can I eat or drink before my procedure?
You should refrain from eating at least 6 hours before your procedure. You may drink clear fluids until 2 hours prior to your procedure.
Do I take my medications on the day of the procedure?
Unless advised by your doctor, you should continue to take your usual medications with water.
However, your doctor may advise you to stop taking or adjust your diabetic medications, and/or to stop certain blood thinners 2-5 full days prior to your procedure.
Where do I go to have the procedure?
Coronary angioplasty and stenting is performed at Peninsula Private Hospital in the cardiac catheterisation laboratory (‘cath lab’).
For all interventional procedures, you will need to remain in hospital overnight.
What do I need to bring?
Your hospital admission paperwork with a signed consent form, health insurance details and Medicare /DVA card. Bring your usual medications in their original packaging.
Bring an overnight bag, as you will be required to stay in hospital for monitoring after the procedure.
What do I wear?
Wear clothing that is easy to remove as you will be asked to change into a hospital gown prior to the procedure.
How much will it cost?
Doctors at Peninsula Heart Centre do not charge any out of pocket fees for your procedures at Peninsula Private Hospital. Our doctors subscribe to the ‘No-Gap-Scheme’ and patients will not be charged any extra fees (your private health insurance covers the gap).
What happens during the procedure?
Exam and set up
- Prior to commencing the procedure, the cath lab staff will review your medical history, blood tests, allergies and medications that you take.
- They will check your vital signs (blood pressure and pulse).
- You will be asked to change into a hospital gown. The groin and wrist will be prepped by clipping the hair in the area.
- An IV line will be inserted into a vein in your arm to allow for administration of fluid and drugs if required. You will be given oral sedation consisting of Valium and Phenergan as well as intravenous sedation with Midazolam if required.
- You will be given a local anaesthetic to numb the area in your wrist or your groin.
- Our cardiologists routinely use a vascular ultrasound machine to guide the puncture of these arteries, to ensure correct insertion of the sheath, to reduce the likelihood of trauma or complications afterwards.
- A hollow sheath will then be inserted into the blood vessel (the femoral artery at the groin or the radial artery at the wrist) to allow the passage of the heart catheters.
- A long, thin, flexible tube (catheter) is then passed through the sheath and into the artery, up the aorta (main blood vessel in the body) to the heart. You will not feel the catheters move within the body.
- Dye will then be injected through the catheter into your arteries.
- X-rays will be taken as the dye moves through the blood vessels, to see if your coronary arteries are narrowed or blocked. A series of X-Ray images are taken throughout the angiogram procedure.
- To complete the angiogram assessment, the doctor will pass a special catheter into the left ventricle and inject a small volume of contrast to check the heart muscle strength. It is during this time you may feel a warm flush.
Angioplasty/stenting (Percutaneous coronary intervention – PCI)
- If there is a significant blockage and it is amenable to fixing at the time a guide wire is advanced beyond the narrowed portion of the artery. A catheter with small balloon at the end is passed across the narrowed area and inflated, then deflated and removed from the vessel. The pressure from the inflated balloon presses the plaque against the wall of the artery, improving blood flow.
- In some instances, coronary artery blockages may not easily yield to balloon dilatation due to calcium. Additional preparations may be required using rotablator (fine drill).
- In 90% of all angioplasties, a stent is then permanently inserted into the artery. The stent is inserted via a catheter and dilated to scaffold the narrowed or recently angioplastied section of the artery
- The mesh-like stent allows cells lining the blood vessels to grow through and around the struts. This typically takes 2-6 months, during which time you are required to take two blood thinners to avoid clots from forming inside the stent.
- Occasionally the narrowed artery may be dilated with a special drug coated balloon. This balloon emits a drug during the healing period that prevents scarring and re narrowing of the vessel.
- The catheter and sheath will be removed and firm pressure applied to the access site either via a pressure device or by manual compression.
Will I feel any pain?
The coronary intervention (PCI) is not a painful procedure although at times you may feel uncomfortable as the balloon and stent block the artery during inflation. This will resolve once deflation occurs and blood flow is restored.
- You will be awake for the procedure but you will be given antihistamine and sedation, (Phenergan and Valium) prior to the procedure as well as intravenous sedation (Midazolam) if required.
- Threading the catheter shouldn’t cause pain and you shouldn’t feel it moving through your body. Tell your doctor if you do experience any pain or feel unwell at any time.
How long does the procedure take?
Depending on the complexity and number of blockages, an angioplasty and stent procedure PCI may take approximately 1-2 hours.
Following the coronary intervention, you will be transferred directly to Coronary Care for an overnight stay and monitoring.
What are the risks?
While serious risks are unlikely, as with all medical procedures, there are some associated risks.
Most common risk:
- bruising or swelling at the puncture site.
- injury to the artery at the puncture site resulting in blockage or false channel. This may require vascular surgery to repair the artery.
- allergic reaction to the X-ray contrast dye. Medications are given to reduce this likelihood.
Rare but serious complications:
- damage to one of the coronary arteries requiring further stenting or urgent coronary bypass surgery.
- Abnormal rhythm caused by coronary spasm or injection of contrast into small vessels requiring urgent defibrillation
- heart attack caused by blocking off one of the coronary arteries.
- a stroke caused by a plaque being displaced and travelling to the brain.
- Acute blockage of the stent within 24 hours.
- Late stent blockage within 6 months due to excessive scar formation or premature cessation of blood thinners.
Please discuss concerns you may have regarding risks associated with the procedure.
After the procedure
After PCI, you will be moved to the coronary care unit. Your heart rate, pulse and blood pressure will be closely monitored. The artery access site will be checked routinely. ECG is performed to identify any problems during your stay. Blood tests may be performed the next day.
You can usually start ambulating within 2 – 6 hours after stenting.
You will need to organise for someone to come and pick you up from the hospital to take you home after the procedure.
Drink plenty of fluids to help flush the X-ray contrast from your body.
You will be given two blood thinners (anti-platelet agents like aspirin PLUS clopidogrel / ticagrelor / prasugrel) after stent to help prevent the formation of blood clots within the metal stent. You will be required to take these 2 medications for 2 – 12 months after the procedure.
What will I need to do after I go home?
Avoid strenuous activities and heavy lifting for 24 hours.
Refrain from driving for 48hrs post PCI
Call Peninsula Heart Centre (03 9789 0088) if you experience:
- Bleeding, new bruising/swelling or increased pain at the catheter puncture site.
- Signs of infection such as redness, pain or swelling.
- Change in colour, strength or numbness of the leg/arm that was used for the procedure.
- Sudden onset chest pain or shortness of breath.
Results and follow-up
Our cardiologists will give you the results of your coronary angioplasty and stent/PCI after the procedure. You will be provided with images of your coronary arteries before and after the PCI, a summary of the procedure and after-care instructions. Follow-up appointments will be made on discharge. A copy of your results will be provided to your referring doctor and a copy placed in your medical history.