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Procedures done for coronary artery disease atherectomy angioplasty (PTCA) stent coronary artery bypass surgery (CABG) enhanced external counterpulsation (EECP)

Angioplasty (PTCA)

Angioplasty is a procedure that opens blocked heart arteries, relieves symptoms of coronary artery disease and improves blood flow to the heart. During angioplasty, a catheter with an inflatable balloon at the tip is passed into a blocked heart artery. The balloon is inflated at the site of blockage, compressing the cholesterol buildup, and opening the narrowed part to improve blood flow. Then, the catheter with the balloon is removed. Angioplasty will open blocked arteries and improve blood flow to your heart. It relieves symptoms, improves exercise duration, and in some cases stops or prevents heart attacks.

It is often more effective than medications in relieving symptoms in patients with a blockage in one artery. Following an angioplasty, many patients can stop or reduce their number of heart medications.

Angioplasty is also called percutaneous transluminal coronary angioplasty (PTCA), coronary artery balloon dilation or balloon angioplasty. Angioplasty increases the flow of blood and oxygen through a clogged heart artery without surgery. A physician uses an instrument called a catheter equipped with a tiny balloon to widen the opening in a partially blocked artery.

Angioplasty can be used to treat almost all blockages. It is fairly simple and has a low complication rate. Inova cardiologists are very familiar with the technique. It has been the most commonly performed therapeutic invasive procedure. Its use has declined since the introduction of newer procedures such as stents, atherectomy, and laser. Stents may lower the risk of restenosis for some blockages. Angioplasty has less favorable results in blockages with calcium deposits or blockages at artery branch points. Rotational atherectomy or laser may be preferable to angioplasty in these patients.

Angioplasty is initially successful in about 95% of patients. However, about one-third of patients will develop a recurrence of the blockage (called restenosis). This occurs because the angioplasty procedure is designed to crush the blockage against the artery wall. The artery's healing process can cause an overgrowth of cells and substances that cause a recurrence of the blockage. This usually occurs during the first six months. Your doctor will follow you closely for a return of symptoms and may even perform a follow-up exercise stress test. If a blockage returns, you can be treated with medications, with a second angioplasty or other interventional procedure, or possibly with bypass surgery. Only about 25% of patients will need a repeat angioplasty.

Angioplasty may be performed on the arteries of the heart, neck or legs. The same general procedure is used; however it may vary slightly from location to location. A thin tube called a catheter is used to perform the angioplasty. At the end of the catheter is a tiny, inflatable balloon. The catheter is inserted through the skin into an artery, usually in the groin area. Before the catheter is inserted, the skin over the artery is cleaned the hair in the area is shaved. Next, a local "numbing" medication is injected under the skin to provide local anesthesia. The person may also be given a mild sedative to relax.

A small skin incision is then made at the site. The tube is passed over a wire, which is used to guide it, and into the artery. The part of the tube that contains the inflatable balloon is positioned at the point of the blockage. In order to know exactly where to position the balloon, an x-ray test is performed to position the catheter and balloon, as well as to "map" the affected arteries. These x-rays are taken in "real time," meaning, that instead of taking one picture, multiple images are obtained one after the other. This helps the surgeon position the wire, the tube, and the balloon, and look at the areas of blockage in the arteries. This procedure involves squirting a contrast agent into the artery. The contrast agent outlines the artery so that the contours show up when x-ray images are taken. In this way, the surgeon can see the blockage.

After being positioned, the balloon is inflated. When the balloon is inflated, it expands inside the clogged artery. The expanding balloon forces the blockage to open by pushing the walls of the artery outward. The artery then remain open because the walls are stretched and some of the deposits on the walls are broken up. This restores blood flow through the artery. Another set of x-rays is taken after the procedure to ensure that the artery has been successfully opened. If these images confirm that the angioplasty restored blood flow, the procedure is over. If not, the process can be repeated. In some cases, the angioplasty may not be successful and the procedure is stopped. If this occurs, other treatment options must be considered, such as heart bypass surgery. In either case, the tube is removed and the skin incision is bandaged.

People who have had angioplasty can usually start walking within 12 to 24 hours and have an average hospital stay of only 1 to 2 days. Although angioplasty sounds far less traumatic than bypass surgery, the latter may be considered a better option for some people, such as those with diabetes. If you think that you or a loved one may be a candidate for angioplasty, be sure to meet with your doctor to discuss the benefits and risks associated with this and/or alternative treatments.

Coronary Angioplasty

Coronary angioplasty is a medical procedure during which narrowed arteries that supply blood to the heart muscle are widened, to allow for improved flow of blood through these arteries to the heart, without the need for open heart surgery. The purpose of angioplasty is to widen narrowed or blocked arteries, so that enough blood can get to the heart to deliver the oxygen it needs to function properly. Angioplasty is designed to relieve the chest pain a person usually feels when the heart is not getting enough blood and oxygen. A successful angioplasty will improve symptoms such as chest pain and shortness of breath, and may improve survival in a limited number of individuals.

One way to unblock (open up the lumen) of a coronary artery (or other blood vessel) is angioplasty, or Percutaneous Transluminal Coronary Angioplasty (PTCA). A wire is passed through the diseased coronary artery, to beyond the area of coronary artery that is being worked upon. Over this wire, a balloon catheter is passed into the segment that is to be opened up. The end of the catheter contains a small folded balloon. When the balloon is hydraulically inflated, it compresses the atheromatous plaque and streches the artery wall to expand. At the same time, if an expandable wire mesh tube (stent) was on the ballon, then the stent will be implanted (left behind) to support the new stretched open position of the artery from the inside.

Angioplasty and stenting is performed through a thin flexible catheter during Cardiac Catheterization, often making heart surgery unnecessary. While coronary angioplasty has consistently been shown to reduce symptoms due to coronary artery disease and to reduce cardiac ischemia, it has not been shown in large trials to reduce mortality due to coronary artery disease.

Traditional ("bare metal") coronary stents provide a mechanical framework that holds the artery wall open, preventing stenosis, or narrowing, of arteries feeding critical structures like the myocardium. Traditional stenting is superior to angioplasty alone in keeping arteries open.

Patients are most often referred for angioplasty after presenting with an abnormal stress test, angina pectoris, unstable angina pectoris or a myocardial infarction (MI or heart attack). In general narrowing of the lumen of the coronary artery must be at least 70% before an angioplasty is considered. You will be awake and often sedated and so you will be sleepy. A catheter is placed into the coronary artery and an angiogram is taken. A small wire is chosen and is placed down the artery past the narrowing into the artery. A small balloon is then passed over the wire to the narrowing and inflated to open the balloon and compress the blockage in the artery. You may fell angina or chest pain during this portion of the procedure, this is common and usually resolves within minutes of deflating the balloon. The balloon is inflated for one half a minute to ten minutes. If the artery is opened and blood flow near normal the balloon and wire are removed and a final angiogram is taken. If the results are acceptable the catheters are removed and you will return to your room. After a few hours the blood thinners are allowed to dissipate and a staff member will remove the sheath (tube) in the artery. You will need to lay flat for an additional 4 to 12 hours. The success of angioplasty procedures varies depending on the patient. There are also a number of potential complications and you need to discuss these with your doctor before the procedure.

Newer stents (called drug-eluting stents) are coated with drugs that prevent re-stenosis of the artery. Two drugs, sirolimus and paclitaxel, have been demonstrated effective and safe in this application by stent device manufacturers and are being used in the US.

Risks of angioplasty include myocardial infarction, cardiac arrhythmia, bleeding and death. These events, fortunately, are uncommon, and the procedure is widely practiced. Coronary angioplasty is usually performed by an interventional cardiologist, a medical doctor with special training in the treatment of the heart using invasive catheter-based procedures.

Balloon Angioplasty

Balloon angioplasty, also known as percutaneous transluminal coronary angioplasty (PTCA), uses a small, thin tube (called a catheter) with a tiny balloon at its tip. The tube is inserted into the bloodstream through a large vessel in the arm or leg. By watching the progress of the tube on an X-ray, the cardiologist guides the tube into the heart, where it is inserted into a narrowed coronary artery. The tiny balloon is then inflated to widen the narrowed area.

Patients with unstable angina have severe coronary artery narrowing and are at imminent risk of heart attack. In addition to angina medications, they are given aspirin and the intravenous blood thinner, heparin. A new form of heparin, Lovenox , may be administered subcutaneously, and has been demonstrated to be as effective as intravenous heparin in patients with unstable angina. Aspirin prevents clumping of blood clotting elements called platelets, while heparin prevents blood from clotting on the surface of plaques. While patients with unstable angina may have their symptoms temporarily controlled with these potent medications, they are often at risk for the development of heart attacks. For this reason, many patients with unstable angina are referred for coronary angiography, and possible PTCA or CABG.

PTCA can produce excellent results in carefully selected patients who may have one or more severely narrowed artery segments which are suitable for balloon dilatation, stenting, or atherectomy. During PTCA, a local anesthetic is injected into the skin over the artery in the groin or arm. The artery is punctured with a needle and a plastic sheath is placed into the artery. Under x-ray guidance (fluoroscopy), a long, thin plastic tube, called a guiding catheter, is advanced through the sheath to the origin of the coronary artery from the aorta. A contrast dye containing iodine is injected through the guiding catheter so that x-ray images of the coronary arteries can be obtained. A small diameter guide wire (0.014 inches) is threaded through the coronary artery narrowing or blockage. A balloon catheter is then advanced over the guide wire to the site of the obstruction. This balloon is then inflated for about 1 minute, compressing the plaque and enlarging the opening of the coronary artery. Balloon inflation pressures may vary from as little as one or two atmospheres of pressure, to as much as 20 atmospheres. Finally, the balloon is deflated and removed from the body.

Intracoronary stents are deployed in either a self-expanding fashion, or most commonly they are delivered over a conventional angioplasty balloon. When the balloon is inflated, the stent is expanded and deployed, and the balloon is removed - the stent remains in place in the artery. Atherectomy devices are inserted into the coronary artery over a standard angioplasty guide wire, and then activated in varying fashion, depending on the device chosen.

PTCA is performed in a special room fitted with computerized x-ray equipment called a cardiac catheterization laboratory. Patients are mildly sedated with small amounts of diazepam (Valium), midazolam (Versed), morphine, and other sedative narcotics given intravenously. Patients may experience minor discomfort at the site of the puncture in the groin or the arm. Patients also may experience brief episodes of angina while the balloon is inflated, briefly blocking the flow of blood in the coronary artery. The PTCA procedure can last from 30 minutes to 2 hours, but is usually completed within 60 minutes.

Long-term benefits of PTCA depend on the maintenance of the newly-opened coronary artery(ies). 30-40% of patients with successful PTCA will develop recurrent narrowing (restenosis) at the site of the balloon inflation, usually within 6 months following PTCA. Patients may complain of recurrence of angina or may have no symptoms. Restenosis is often detected by exercise stress tests performed at 4 to 6 months after PTCA. Restenosis occurs with a significantly higher frequency in patients with diabetes. The rate of restenosis is greater in vein grafts, at the origins of vessels, in the beginning part of the left anterior descending coronary artery, and in those with suboptimal initial results. The widespread use of intracoronary stents has reduced the incidence of restenosis by as much as 50% or more; this is due to prevention of "elastic recoil" in the artery, as well as providing a larger initial channel in the treated artery.

Peripheral Angioplasty

Peripheral angioplasty is a procedure that helps open blockages in peripheral arteries. A tiny incision is made in your groin. This is the insertion site. Your vascular surgeon will insert a catheter into the side and slide it through an artery while viewing a video monitor. A contrast dye is then injected into the catheter and x-ray images are taken. A tiny balloon is pushed through the catheter to the blockage. The surgeon will then inflate and deflate the balloon a few times to compress the plaque. The balloon and catheter are then removed.

This technique is most often used for blockages in arteries that supply blood to your legs or arms, but sometimes is used for kidney arteries. There may be a role for angioplasty of the carotid arteries, though blockages of these arteries are most commonly treated surgically. Once the plaque is pressed back against the artery wall, your doctor may decide to place a device called a stent into the artery to help keep the artery open. A stent is a small tube-shaped mesh screen that is implanted in the artery permanently at the site of the blockage. It allows blood to pass freely through it while it helps to keep the plaque from reforming.

The same risk factors for coronary artery disease are associated with peripheral vascular disease. Controlling these factors can help control symptoms.

There are noninvasive tests, which may help your doctor learn if the blood flow through the arteries is impeded and if so may order an angiogram. The procedure of peripheral angioplasty is performed using a catheter and a balloon to expand a narrowed artery. Stents are often used to help keep an artery opened. The procedure is performed under local anesthesia and sedation. You may have your procedure as an outpatient or stay overnight. Light activity may be resumed shortly after the procedure and full activity in about one week.

Laser Angioplasty

Laser angioplasty uses a catheter with a tiny laser at its tip instead of a balloon. Once inside the coronary arteries, the laser emits pulsating light beams that destroy areas of fatty deposits containing cholesterol (called plaque) that narrow the arteries.

Laser angioplasty is a technique that opens coronary arteries blocked by plaque. Plaque is the build-up of cholesterol and other fatty substances in an artery's inner lining. In this technique, a thin, flexible plastic tube called a catheter with a laser at its tip is inserted into an artery. Then it's advanced through the artery to the blockage in the coronary artery. When the laser is in position, it emits pulsating beams of light. These vaporize the plaque.

This procedure has been used alone and with balloon angioplasty. The first laser device (the "eximer laser") for opening coronary arteries was approved by the Food and Drug Administration in 1992. It's available in many major U.S. medical centers, but isn't used very often because of advances in other techniques..

Whether to use coronary artery bypass surgery, balloon angioplasty with or without stenting or the laser depends upon various factors. They include where the blockage is, how many blockages there are, and the extent of the blockage(s). Patients should discuss their options with their physicians.

Laser is initially successful in about 90% of patients. However, 30 to 60% of patients will develop a recurrence of the blockage (called restenosis). This occurs because laser injures the artery. The artery's healing process can cause an overgrowth of cells and other substances that cause a recurrence of the blockage. Restenosis usually occurs during the first six months. Your doctor will follow you closely for a return of symptoms and may even perform an exercise stress test. If a blockage returns, you can be treated with medications, a second laser or other interventional procedure, or possibly bypass surgery.

Laser angioplasty is frequently done when there is a blockage inside a prior intracoronary stent. Again, just as with atherectomy, your physician will do a balloon angioplasty after the Laser part of the procedure, in order to compress any remaining plaque against the wall; thus leaving a wider path for blood to flow to the heart.

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