Coronary Angioplasty and Stenting

Coronary Angioplasty (Percutaneous Coronary Intervention) is a minimally invasive procedure that involves inserting a small balloon catheter into a narrowed or blocked artery to open up the blocked artery. This helps to improve the blood flow to the heart muscles.

A small wire mesh tube, known as the stent, is often implanted during an Angioplasty which props the artery open and reduces the chances of the artery narrowing again. Most modern stents are coated with medication which is released gradually to prevent narrowing within the stent and to keep the artery open.

Coronary Angioplasty is performed to improve symptoms of narrowed or blocked arteries such as chest pain (angina) and shortness of breath. Coronary Angioplasty is also performed during a heart attack to immediately open an acutely blocked artery and lessen the damage to the heart. Performed emergently during a heart attack, Angioplasty is potentially life-saving.

Patients may need to go for an Angioplasty if:

• They have severely narrowed arteries
• They are experiencing symptoms of coronary artery disease such as chest pain or shortness of breath
• They are experiencing chest pain that is getting worse
• They are having a heart attack, as Angioplasty can immediately open a blocked artery, lessening the damage to the heart

Coronary artery disease develops when the arteries that supply blood to your heart become narrowed or blocked by a build-up of fatty cholesterol deposits called plaque. This process is known as atherosclerosis and develops over time. Angioplasty is a procedure used to treat the build-up of plaque to open up severely narrowed or blocked coronary arteries.

Source: Boston Scientific Cardiology

Rotational atherectomy, also called rotablation, is a specialised procedure used in percutaneous coronary intervention to ablate severely calcified plaque in the coronary artery. Rotational atherectomy is performed with a rapidly rotating olive-shaped burr coated with microscopic diamond chips. The burr rotates at very high speeds to drill through the calcified plaque, creating a channel and weakening the hard calcium for balloons and stents to expand. Rotational atherectomy is usually performed prior to stenting in a very calcified plaque where balloon angioplasty alone is insufficient to crack open the blockage.

Source: Abbott Vascular

Orbital atherectomy is another technique used in percutaneous coronary intervention to ablate severely calcified plaque in the coronary artery. Orbital atherectomy uses the Diamondback 360™, a diamond-coated crown that orbits 360 degrees at high speed and creates differential sanding of calcium. It is particularly useful if the calcified area is long (‘diffuse disease’), heavily blocked (‘stenosed’), presence of nodular calcification, and calcium occurring at the start of the vessel (‘ostial lesions’). Orbital atherectomy is usually performed prior to stenting in a very calcified plaque where balloon angioplasty alone is insufficient to crack open the blockage. After orbital atherectomy, the vessel expands and allows the stent to be implanted with good expansion of the stent.

Source: Shockwave Medical

Intravascular Lithotripsy (IVL) is a specialised procedure used in percutaneous coronary intervention to break severely calcified plaques in the coronary artery using sonic waves. Intravascular lithotripsy uses a special balloon catheter with lithotripsy emitters which delivers multiple pulses of sonic waves to fracture calcium. Once the hard calcium is fractured, the blockage is weakened sufficiently for balloons and stents to expand. IVL is usually performed prior to stenting in a very calcified plaque where balloon angioplasty alone is insufficient to crack open the blockage. IVL was developed using the same technology in the treatment of kidney stones.

Both Rotational Atherectomy and Intravascular Lithotripsy may be used in the same procedure to open up the calcified plaque before stenting.

Dr Joshua Loh also performs Robotic Percutaneous Coronary Intervention (R-PCI). Robotic percutaneous coronary intervention (R-PCI) provides a new approach to the procedure, allowing the Cardiologist to remotely control technology to manipulate guidewires and catheter devices with greater depth perception, range of movement and accuracy. This combines the Interventional Cardiologist’s skill, critical thinking and eye for detail with the precision of a machine.

Angioplasty may not be suitable for all patients with coronary artery disease. Depending on the severity and extent of the artery narrowing and the general state of health, your cardiologist may recommend either Angioplasty or coronary bypass surgery.

Coronary bypass surgery may be needed if:

• There are multiple severe blockages in the arteries
• There are complex blockages not suitable for Angioplasty
• There are extensive narrowings in the arteries of patients with Type 2 diabetes
• The heart muscle is severely weak

Coronary bypass surgery is done under general anaesthesia. During the surgery, the surgeon takes healthy blood vessels from the chest, arm or leg to create a graft to bypass the blocked coronary arteries. This new path allows blood to flow around the blocked or narrowed artery, improving blood flow to the heart muscles.

In general, major complications such as heart attack, abnormal heart rhythm, stroke, injury to the blood vessels, major bleeding, drug allergy, weakened kidney function, need for emergency surgery, and death is very rare and occur in less than 1% of patients undergoing Angioplasty. This risk depends on the complexity of blockages and the patient’s underlying medical conditions, and may therefore be higher if the patient has other comorbid conditions, e.g. advanced age, renal failure.

Other less serious complications occur uncommonly in 1-3% of patients and include bleeding, bruising and swelling of the puncture site, and blood clot formation in the artery where the sheath is inserted. The other risks are related to local anaesthesia, sedation, and blood transfusion. Overall, the procedure is very safe and well-tolerated. Your cardiologist will go through with you in detail the specific risks involved before the procedure.

Your cardiologist will carefully review your medical history and do a physical examination, as well as perform diagnostic tests before scheduling you for an Angioplasty. Some routine tests before the procedure may include blood tests, an electrocardiogram, and a chest X-ray.

Your cardiologist will perform a coronary angiogram to visualise the arteries and locate the narrowing. To visualise the coronary arteries, a small tube (catheter) is inserted via the wrist or groin artery and positioned at the coronary artery opening. Under live Xray guidance, a special dye is injected through the catheter into the arteries. Depending on the outcome of the coronary angiogram, your cardiologist will decide if the artery narrowing can be treated by Angioplasty. Angioplasty can be performed in the same setting as the coronary angiogram, using the same access to the arteries.

To prepare for your procedure, please inform your cardiologist of the following:

• The medications that you are currently taking. Some medications need to be stopped before the procedure.
• Any allergies or any medications you cannot take.
• Any bleeding problems you may have.
• Any surgery or dental work you may have soon.
• If you are pregnant, nursing, or have any plans to get pregnant.

Your cardiologist will give you a set of specific instructions before the procedure:

• Fast for at least 6 hours before the procedure.
• Do not take your diabetic medications on the day of the procedure.
• On the day of the procedure, take only the approved medications with tiny sips of water. Ensure that all the other necessary medications are packed to take to the hospital.

Before the procedure, your cardiologist will usually give you a sedative to help you relax. You will be cleaned and draped with sterile towels. A local anaesthetic will be injected at the puncture site at the wrist or groin to numb the area. Next, a plastic tube called a sheath is inserted into the wrist or groin artery. You might feel some pressure at this time. During the Angioplasty, you may feel minor discomfort when the balloon is being inflated as it stretches the artery. Otherwise, you should not experience any sharp pain during the procedure.

After Angioplasty, you will need to rest in bed for at least 4 hours. Your blood pressure, heart rate and puncture site will be monitored closely. You will likely stay overnight for observation and be discharged the next day if there are no issues. You are encouraged to make prior arrangements for someone to bring you home, especially if you have been given sedatives. Some of your medications may be adjusted on discharge.

Do drink plenty of fluids to help the body flush out the contrast dye once you return home. Please do not drive for the next 24 hours after the procedure. Avoid any kind of strenuous exercise and do not lift heavy objects for a few days. Do check with your cardiologist or nurse regarding other activities. You should be able to return to your normal routine a week after the procedure.

To maintain a healthy heart after Angioplasty, we strongly recommend the following:

• Stop smoking
• Reduce and manage stress
• Eat a healthy diet full of nutritious food
• Maintain an active lifestyle with regular exercise
• Monitor and manage your cholesterol, blood pressure, and blood sugar levels
• Take all the necessary medications prescribed by your cardiologist
• Visit your cardiologist for regular check-ups