• Your Angioplasty and Stenting Procedure

     
     
     
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    If your physician has determined that you have blockages in your arteries and that you are a good candidate for angioplasty and/or stenting, you likely have many questions about treatment. Read on to learn more about what happens before, during, and after your procedure.

    1. How Your Doctor Will Assess Treatment Options
    2. Questions to Ask Your Doctor
    3. The Procedure
    4. Accessing the Artery
    5. The Members of the Care Team
    6. After Your Procedure

     


    How Your Doctor Will Assess Treatment Options

    As with any medical procedure, angioplasty alone or in combination with stenting is the right treatment for patients who meet certain criteria. If you have blockages in your arteries, your physician will assess the severity of your cardiovascular disease and where you best fit among a range of treatment options – sometimes referred to as the spectrum of care. The spectrum of care options for cardiovascular disease consist of a combination of treatments including -- 

    • Lifestyle changes 
    • Medications  
    • Revascularization, or treatment to re-establish blood flow through a narrowed artery. Options for revascularization include:  
      • Angioplasty and stenting and other interventional procedures
      • Bypass surgery 

    Some patients may be at the beginning stages of cardiovascular disease. In this case, changing lifestyle elements such as diet and exercise might be enough to get you back on track for good health. For other patients, medication in addition to lifestyle changes can slow or reverse the progress of cardiovascular disease. For patients with more advanced disease, revascularization, in addition to medication and lifestyle changes may be necessary. 

    Your interventional cardiologist will work in conjunction with other healthcare providers to determine which treatment options are likely to benefit you most. These treatment decisions are based on education and experience, as well as being grounded in practice guidelines – standards developed by leading experts in the field of cardiology to guide the profession. These frequently updated guidelines are drafted after careful review of all the peer-reviewed information and data available. Interventional cardiologists use the 2009 Focused Updates: STEMI and PCI Guidelines jointly developed by the American College of Cardiology, American Heart Association, and the Society for Cardiovascular Angiography and Interventions, as well as guidelines developed by the European Society of Cardiology.

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    Dr. Mark Turco explains what is meant by “evidence-based medicine,” a term often used to explain how physicians and other healthcare providers arrive at recommendations for the care of individual patients.

    Throughout the decision-making process, the patient is also a core member of the care team. You can help your interventional cardiologist determine which treatment options make the most sense for you based on desired quality of life. Participating in your own care starts with something as simple as writing down questions you may have about the procedure and bringing that list to your next appointment. Your interventional cardiologist can work with you to find a truly individualized treatment. 

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    Questions to Ask Your Doctor

    A few basic questions can serve as a great starting point for a conversation with your interventional cardiologist about whether angioplasty and stenting is right for you and what you should do before, during, and after the procedure. Not all patients who receive angioplasty will also require a stent. The decision about whether to insert a stent is guided by factors such as the location of the blockage and the likelihood of a reopened artery collapsing after angioplasty alone. Some sites where arteries branch or can bend are not good candidates for stenting. Most of the questions below apply to angioplasty alone or in conjunction with stenting.

    Print out or write down these questions and take them with you to your appointment. Taking notes can help you recall your interventional cardiologist's responses once you return home. 

    • What are the benefits of the procedure for me?
    • What are the risks of angioplasty and stenting for me?
    • What are my alternatives?
    • Could I be treated with medicines instead of angioplasty and stenting?
    • Will angioplasty and stenting save my life?
    • Do I need a stent, or would angioplasty alone be just as effective?
    • How long will I need to stay in the hospital?
    • How long after the procedure before I can get back to my regular routine?
    • What limitations will I have after the procedure, both short and long term?
    • What follow-up is necessary after the procedure? What do I need to do?
    You can also click on the questions below to view video answers to common patient questions from experts from the Society for Cardiovascular Angiography and Interventions (SCAI). These responses are not a substitute for a conversation with your treating physician, but they can help you understand your treatment options.

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    The Procedure

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    What Will You See in the Cath Lab? Angiogram tests and angioplasty procedures are performed in special hospital rooms called cardiac cath labs. In this video, Dr. John P. Reilly gives you a guided tour of the cath lab, pointing out the equipment you’ll see and explaining what it’s for. (Video provided courtesy of Dr. Reilly)

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    Watch this video to learn more about how angioplasty is performed. (Animation provided courtesy of Boston Scientific Corporation)

    An angioplasty procedure is performed in the catheterization laboratory, or “cath lab,” in a hospital. Your physician for the procedure is called an interventional cardiologist, a cardiologist with additional education, training and experience in treating cardiovascular problems via use of thin flexible tubes called catheters. Before the procedure, your interventional cardiologist will review any risks of the procedure and the anesthesia that will be used, as well as obtain your informed consent, which gives your physician permission to perform the procedure.

    You will lie on a table and be mildly sedated to help you relax, but you will remain awake throughout the procedure. The process below describes angioplasty for coronary artery disease. If angioplasty will be performed to treat a different condition, ask your physician for details of the procedure.

    The doctor will use a small needle to inject lidocaine, a local anesthetic, to numb an area in the groin, or upper leg, or in the arm. (This needle prick could be the only pain you will feel throughout the procedure.) The femoral artery in the groin – near where your leg bends from the hip – is one of the vessels doctors commonly use to insert the catheter and thread it through the arteries to the heart to perform the angioplasty. Instead of the femoral artery, your doctor may choose to insert the catheter in the brachial or radial artery in the inside of the elbow or wrist. 

    From this access point in your leg or arm, a guiding catheter is threaded through the arteries to your heart. (Since there are no nerves in your arteries, you will not feel the catheter.) An x-ray camera and images of your arteries on a television screen help the physician guide the catheter to the blockage. 

    When the guiding catheter is properly positioned, the cardiologist injects a contrast dye (radiographic contrast agent) through the catheter into the heart and its arteries. Most people do not feel the dye injection. However, some feel minor discomfort or a warm sensation, typically lasting only a few seconds, in their chest. A few feel lightheaded or nauseous.

    If a blockage is found, a guidewire – a tiny, thin wire of about 0.014 inches diameter – is then passed across the narrowed segment. It serves as a support for positioning the tiny balloon across the blockage. Next the balloon catheter – a long, thin flexible tube with a small uninflated balloon at its tip – is threaded through the guiding catheter over the guidewire and into the artery to where the artery is narrowed. 

    Once in position, the balloon is inflated with saline and x-ray dye. (The balloon may be inflated several times.) When fully inflated, the balloon pushes the plaque against the wall of the artery. Some patients feel minor discomfort when it is inflated. If you have more than minor discomfort, medication to relieve it can be given immediately. As the balloon inflates, plaque that extends into the wall of the artery may tear or crack. This is normal and necessary. 

    Once the balloon is deflated, x-ray pictures are taken to ensure the blockage is gone. When the balloon catheter is removed, final x-ray pictures are made.

    At the end of the procedure, your care team will work to close the puncture site where the catheter was inserted. For access sites in the groin, manual pressure is applied, sometimes in conjunction with a closure device (when the anatomy is suitable). Common examples of closure devices include a collagen plug as well as a stitch, each of which is designed to close up the hole in the blood vessel. Closure devices may increase patient comfort and decrease the time that the patient needs to remain on bed rest after the procedure, but in general, they have not been found to decrease the rate of bleeding. If a radial artery approach is used to perform the procedure, the closure devices are slightly different from those used in the groin and generally consist of bands that go around the wrist, with either air (for compressive purposes) or compounds that stop bleeding in the band.

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    Accessing the Artery

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    Dr. Kimberly Skelding discusses the benefits of radial angioplasty, where a blocked heart artery is accessed from the wrist.

    Your interventional cardiologist can choose to insert a catheter through one of two access points in your body: an artery near the groin for femoral angioplasty and an artery in the wrist for what is called radial angioplasty. Use of the radial technique, though practiced safely abroad for years, is relatively new to the United States. More widespread adoption of radial angioplasty in the United States is the expected trend in coming years. Both techniques have high proven safety levels demonstrated through studies. 

    Radial angioplasty, when available and indicated for the patient, presents a few advantages for patients and hospitals. Patients who have angioplasty performed through a puncture site in the wrist do not have to lie flat for hours after the procedure as do femoral artery patients. Radial angioplasty patients can typically sit up or walk around as soon as anesthesia permits. They can also eat or drink soon after the procedure. However, not all patients can have angioplasty performed via radial access. Some patients are not good candidates for radial access. These patients will undergo femoral angioplasty.

    Look for more hospitals to adopt radial angioplasty as more interventional cardiologists in the United States receive training in artery access through the wrist. Radial angioplasty is also likely to become more common in the United States once specialized catheters are approved for use. In the meantime, interventional cardiologists in the United States – always seeking innovation – have found ways to use already approved catheters to safely complete radial angioplasty.

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    The Members of the Care Team

    During balloon angioplasty, stenting and other catheter-based heart treatments, your interventional cardiologist will be the leader of an entire team dedicated to your care. 

    Among those who will also be part of your care team during an interventional procedure in the hospital's catheterization laboratory are cath lab nurses. These nurses are closely involved in your care from the time you arrive at the cath lab. During the procedure, cath lab nurses assist the interventional cardiologist and monitor your condition to identify changes that may need immediate attention. Technicians and nurses watch the cath lab monitors that display your heart rhythm and rate – and notify the physician if they observe changes.

    After your procedure, nurses continue to provide watchful care in the recovery area. Of particular concern is stopping any bleeding from the puncture site through which the interventional cardiologist threaded the catheter into your arteries. Nurses ask often about how your puncture site (usually in the groin area where the catheter is inserted into your arteries) feels. Plus, they are available to answer questions and teach you how to care for your puncture wound once you leave the hospital.

    Most patients who are treated with angioplasty and stenting are released from the hospital on the day of, or the day after, the procedure. Your interventional cardiologist will inform your cardiologist about the outcome of your procedure. And your cardiologist will, in turn, communicate with your primary care physician. This way, all the key players on your team are kept up to date on your progress.

    If your interventional procedure included insertion of a metal mesh tube called a stent, your interventional cardiologist will provide prescriptions for blood-thinning drugs, such as aspirin and clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta).  It is very important that you follow your interventional cardiologist's instructions for these medications. And even after you begin to feel better, you should never stop taking your medications at any time without speaking with your interventional cardiologist.

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    After Your Procedure

    Recovery from angioplasty and stenting is typically brief. Discharge from the hospital is usually 12 to 24 hours after the catheter is removed. Many patients are able to return to work within a few days to a week after a procedure. 

    What to Expect at Home 

    After an interventional procedure, it is normal to: 

    • Have a bruise or discolored area near where the catheter was inserted. At the same site, there may also be a small lump (which should not get bigger), soreness when pressure is applied and perhaps a small amount (one or two drops) of discharge. 
    • Feel more tired than usual for several days. If your intervention was performed while you were having a heart attack, feelings of tiredness will last longer – perhaps as long as six weeks, the time it takes for healing after an attack. 

    When to call the doctor:

    • If you feel chest pain like you felt before the procedure or during it when the balloon catheter was inflated in your artery. Some patients have chest pain lasting one to two seconds. Typically, they say it feels different from the pain they felt before the procedure. These brief pains are often muscular and are not related to the heart. 
    • If the puncture wound in your leg or arm gets bigger, turns red, drains a thick yellow/brown material or is painful, even when no pressure is applied. A larger, painful lump may be a sign that the puncture hole is not healing properly or is leaking blood. 
    • If you have fever.
    • If you experience swelling – with or without pain – anywhere in the leg in which the catheter was inserted. 

    When to call 911 or go to the hospital:

    • If you have chest pain that lasts 15 to 20 minutes, call 911 or go to the hospital emergency room. 

    Resuming Normal Activities After Your Procedure 

    Always follow your doctor’s instructions about the activity level appropriate for you. A general guide is: 

    • For the first five days, do only light activities. Walking, climbing stairs and taking care of routine activities are fine. After five days, you may resume moderate activities, but you should avoid over exertion that leads to shortness of breath, tiredness, or chest pain. 
    • Wait until three to four weeks before lifting heavy objects or doing strenuous exercise. Get clearance from your doctor before very strenuous activity or manual labor. 

    Follow-up Care

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    What happens after your angioplasty and stent procedure? What can you to help facilitate a healthy recovery and manage your cardiovascular risk factors? Watch this video, provided courtesy of Boston Scientific Corporation, to learn more.

    Once you leave the hospital, your post-procedure care will be two-fold. You will need to take care of yourself by taking medication exactly as prescribed, as well as making lifestyle changes such as exercising, improving your diet, and quitting smoking if you smoke. You should also have at least one follow-up appointment with your treating interventional cardiologist or another qualified specialist if you are not able to return to your treating physician. At this appointment, your interventional cardiologist will examine the catheter insertion site to be sure it is healing properly.

    Occasionally, your doctor may also ask you to take an exercise stress test three to six weeks after your procedure. The results of the test will help guide your doctor in recommending an appropriate level of activity for you. The results may lead to a recommendation that you enroll in an exercise program supervised by health professionals. Supervised cardiac rehabilitation programs are designed to help you build a stronger heart and reduce risk factors for more blocked arteries in the future.

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