Coronary angioplasty is a treatment to widen narrowed sections of the heart (coronary) arteries. It is also known as percutaneous coronary intervention (PCI). It does not involve major heart surgery but involves the use of a catheter which is inserted into coronary arteries via the large blood vessels.
Note: the information below is a general guide only. The arrangements, and the way tests and procedures are performed, may vary between different hospitals. Always follow the instructions given by your doctor or local hospital.
What is coronary angioplasty?
Coronary angioplasty is a procedure where a narrowed section of a heart (coronary) artery is widened by using a balloon and a stent attached to a catheter.
A catheter is a thin, flexible tube which is inserted into a coronary artery. The balloon at the tip of the catheter is blown up at the narrowed section of artery to force it wider. A small tube (a stent) is left in place to keep the artery widened.
What is coronary angioplasty used for?
Coronary angioplasty is commonly used to treat people who have angina. In these people, angioplasty is usually carried out 'electively'. This means a time and date are chosen to do the procedure.
However, angioplasty can also be used to help in emergency situations, such as when a person has a heart attack. A heart attack occurs because part of the heart is not receiving enough blood. This is usually caused by a blockage in an artery supplying blood to the heart itself. Coronary angioplasty is used to widen the artery surrounding the blockage. This helps blood flow back to the affected area and reduces the damage to the heart.
Understanding the arteries of the heart
The heart is mainly made of special muscle. The muscle pumps blood into blood vessels (arteries) which take the blood to every part of the body.
Like any other muscle, the heart muscle needs a good blood supply. The heart (coronary) arteries take blood to the heart muscle. The coronary arteries are the first arteries to branch off the aorta. The aorta is the large artery which takes blood from the left ventricle of the heart to the body.
What is angina and what causes it?
Angina is a pain that comes from the heart. The usual cause of angina is narrowing of one or more of your heart (coronary) arteries. This reduces the blood supply to a part, or parts, of your heart muscle. The blood supply may be enough when you are resting. However, your heart muscle needs more blood and oxygen when it works harder. For example, when you walk fast or climb stairs, your heart rate increases to deliver the extra blood. If the extra blood that your heart needs during exertion cannot get past the narrowed arteries, the heart 'complains' with pain.
The narrowing of the arteries is caused by atheroma. Atheroma is like fatty patches or 'plaques' that develop within the inside lining of arteries. (This is similar to water pipes that become 'furred up' with scale.) Plaques of atheroma may gradually form over a number of years in one or more places in the coronary arteries. In time, these can become bigger and cause enough narrowing of one or more of the arteries to cause symptoms.
The diagram below shows three narrowed sections as an example. But, atheroma can develop in any section of the coronary arteries.
How is coronary angioplasty done?
You lie on a couch in a catheterisation room. An X-ray machine is mounted above the couch. A thin, flexible 'guide' tube (catheter) is inserted through a wide needle or small cut in the skin into a blood vessel in the groin or arm. Local anaesthetic is injected into the skin above the blood vessel. So, it should not hurt when the catheter is passed into the blood vessel. The doctor gently pushes the catheter up the blood vessel towards the heart. Low-dose X-rays are used to monitor the progress of the catheter tip which is gently manipulated into the correct position. You may be able to see the progress of the catheter on the X-ray monitor.
The tip of the catheter is pushed inside a heart (coronary) artery down to where there is a narrowed section caused by the fatty patches, or 'plaques', (atheroma). A second thinner 'balloon catheter' is then passed down the 'guide' catheter. There is a balloon and a small tube (a stent) at the tip of the balloon catheter. The balloon is blown up for 30-60 seconds. This squashes the atheroma and widens the narrowed artery. When the balloon is blown up it stops the blood flow. Therefore, you may have an angina-like pain for a short time. However, this soon goes after the balloon is let down.
Usually, a stent is left in the widened section. The stent is like a wire mesh tube which gives support to the artery and helps to keep the artery widened. The 'collapsed' stent covers the balloon and is opened as the balloon is blown up. Some stents are coated with a chemical that helps to prevent the artery from becoming blocked again. People who are known to have an allergy to nickel may need a nickel-free stent. These are available but are not routinely provided by the NHS.
The procedure may be repeated for one or more other narrowed sections within the coronary arteries.
You cannot feel the catheter inside the blood vessels. You may feel an occasional missed or extra heartbeat during the procedure. This is normal and of little concern. During the procedure your heartbeat is monitored by electrodes placed on your chest which provide a tracing on an electrocardiograph (ECG) machine. Sometimes a sedative is given before the test if you are anxious.
How do I prepare for a coronary angioplasty?
You should receive instructions from your local hospital about what you need to do. The sort of instructions may include:
- If you take any 'blood-thinning' medicine such as warfarin or another anticoagulant, you will need to stop this for 2-3 days before the test (to prevent excessive bleeding from the site of the thin, flexible tube (catheter) insertion).
- If you take insulin or medicines for diabetes, you may need to alter the timing of when you take these. Some medicines may need to be stopped for 48 hours. Your doctor should clarify this with you.
- You may be asked to stop eating and drinking for a few hours before the procedure.
- You may be asked to shave both groins before the procedure.
- You will have to sign a consent form at some point before the test to confirm that you understand the procedure, understand the possible complications (see below) and agree to the procedure being done.
How long does coronary angioplasty take?
If just one section of artery is widened, the procedure usually takes about 30 minutes. If several sections are to be widened then the procedure takes longer. You may need to stay in hospital overnight for observation following the procedure.
How successful is coronary angioplasty?
More than 9 in 10 procedures are successful at relieving angina. However, coronary angioplasty cannot be used for all people with angina. This is because in many cases there are too many narrowed sections in the heart (coronary) arteries. Or, the sections that are narrowed are too long, or too narrow, or too far down a coronary artery or branch artery for this procedure.
After an angioplasty
You should avoid any heavy activities such as lifting for about a week until the small wound, where the thin, flexible tube (catheter) was inserted, has healed. You should not drive a car for a week after having an angioplasty. If you have an LGV or PCV licence, you should check with the DVLA about driving a bus or lorry following an angioplasty.
Are there any possible risks, complications or side-effects?
One common problem is that a bruise may form under the skin where the thin, flexible tube (catheter) was inserted (usually the groin). This is not serious but it may be sore for a few days.
Failure of the procedure
Sometimes it is not possible to stretch the narrowed artery. An alternative treatment for angina called coronary artery bypass grafting may then be an option. However, most people feel that it was worth trying an angioplasty first. This is because, unlike bypass grafting, it does not involve major surgery.
Risks of the procedure
In the vast majority of cases, there are no serious problems. However, you have to accept the risk that in some cases problems do arise:
- The small wound where the catheter is inserted sometimes becomes infected. Tell your GP if the wound becomes red and tender. A short course of antibiotics will usually deal with this if it occurs.
- Rarely, some people have an allergic reaction to the dye that is used to show up the heart (coronary) arteries on X-ray. This is used to help guide the catheter into the correct position.
- Serious complications are rare but do sometimes occur. The risk is mainly in people who already have serious heart disease. Potential serious complications include:
- The procedure sometimes causes the artery to block off completely. If this occurs you may be taken for an urgent coronary artery bypass graft operation (which is usually successful).
- A heart attack during the procedure.
- The catheter may damage a coronary artery. If this occurs, the artery may be repaired by emergency heart surgery.
- A stroke is another rare complication.
- Rarely, some people die during this procedure as a consequence of one of these serious complications.
In some cases, the fatty patches, or 'plaques', (atheroma) re-form within the small tube (stent) over the following few months and years. This may narrow the artery again and angina pains may return. It is difficult to give figures as to how often this occurs. If it does, the procedure can be repeated, or other treatments for angina can be considered, such as coronary artery bypass grafting.
Newer techniques are being developed to try to prevent this possible problem. For example, stents that are coated with chemicals which prevent the local formation of atheroma are being developed. It may be that these coated stents (called 'drug-eluting stents') will be commonly used in the near future.
Dr Tim Kenny
Dr Colin Tidy
Dr Hannah Gronow