CORONARY ANGIOPLASTY ( CORONARY DILATATION)
Coronary angioplasty is the procedure to repair coronary arteries with blockages. This repair follows an examination called coronarography, which allows visualization of coronary strictures.
Dr. Andreas Gruentzig carried out the first coronary dilatation in humans in 1977.
A cardiologist usually makes the request for this examination after meeting the patient.
In the vast majority of cases, coronary angioplasty is performed at the same time as the coronarography procedure. It is possible that the angioplasty is postponed to another day. This happens when several blockages are present or when an artery has been occluded for a long time. These situations require a discussion with the patient in order to offer the best possible option of repair.
This text is written in the context where a second admission is necessary.
Before the exam
Although unlikely, a pre-admission visit may be requested where a blood test will be done as well as an electrocardiogram. All your questions will be answered as the examination is explained to you. This pre-admission usually takes place in the few weeks preceding the intervention.
The day of the exam
One-day hospitalization is usually required for this procedure.
On this day, the patient must be fasting since midnight the day before. This includes not taking any medication unless otherwise indicated during the pre-admission appointment.
Upon arriving in the preparation room, the patient must remove all his or her clothes and wear a hospital gown. A nurse will then install one or two venous accesses through which a solution may be administered. These venous accesses will serve for the administration of medications, as needed, during the examination.
The right wrist and both groins are then shaved for the insertion of the catheters in the artery chosen by the cardiologist.
Preparation in the examination room
At the scheduled time, the patient is sent to the examination room on a stretcher.
During the examination, the nurses and the doctor take the same precautions as in the operating room to avoid the introduction of bacteria into your body (sterile environment). They are dressed in blue or green and wear masks and hats.
The room temperature is cool, cold even, but allows the X-ray machines to run smoothly. To minimize discomfort related to the room temperature, a sterile sheet or blanket covers the patient during the examination.
Two arteries ensure blood circulation of the hand. This circulation has a peculiarity. Connections exist between these two arteries. If one of them crashes, the other one can do cover for it. A test with the hand is often done to verify this permeability.
In some situations, the artery of the wrist (radial artery) cannot be used. In these circumstances, the artery in the groin (femoral artery) will therefore become the entrance to the heart.
There are two benefits of going through the wrist artery. The first one is the decreased risk of bleeding and the second is the possibility of the patient to stand up one to two hours after the exam. However, this access is not always possible and in certain circumstances, access through the groin is more favorable.
The pathway used for the coronary angiography is usually the one reused during the angioplasty. It is however important that other entries are well prepared to respond to all eventualities.
After preparing the material for the exam, the nurse will disinfect both groins and the right or left wrist. Once these areas dry, the nurse places a sterile cover over the patient and plugs in the last instruments. At this point, the patient must limit his or her movements as much as possible.
During the exam
The doctor shows up and the examination begins.
The nurse administers the medications to encourage relaxation and reduce pain during the puncture.
A local anesthesia like the one use by dentist, minimizes the pain.
A small incision is made and a hollow needle punctures the chosen artery.
Not all narrowed arteries are to be repaired
The images of the coronarography are available to the doctor. Not all atheromatous plaques need to be repaired. Coronary angioplasty carries risks and the benefits must surpass them. As a result, coronary angioplasty is performed only on cholesterol plaques that cause a problem to the oxygenation of the heart muscle.
There are situations where the narrowed arteries are at the limit of what the eye considers as requiring angioplasty. In these cases, the doctor will use a special system called the FFR that measures the difference in pressure on each side of the narrowed artery using a very fine wire. It is then possible to determine the expected benefits if the procedure is done.
Material similar to that of coronarography
Like coronary angioplasty, coronary angioplasty uses catheters, dye and X-rays in addition to the equipment needed for repair.
Angioplasty immediately following a coronary angiography
When a coronary angioplasty is done on the same day, the doctor who did the coronary angiography explains to the patient what he or she saw. If possible, the patient is proposed a coronary repair. If agreed upon, we proceed to coronary angioplasty.
A catheter to get the job done
A catheter is installed at the entrance of the sick coronary. The necessary material used to repair the problem will be pushed through it.
Angioplasty crushes atheroma plaque
The goal of coronary angioplasty is to crush the cholesterol plaque that needs to be treated. The plaque breaks under the crushing and exposes the material that causes the clotting. In order to prevent a blood clot formation that would partially or completely block the coronary, intravenous medication is administered to thin the blood.
A small wire acts as the "railroad"
A very fine wire is pushed in the coronary through the plaque to be repaired. It is the "railway" by which all the necessary equipment is sent to fix the problem.
A balloon is used to crush the plaque
A balloon catheter is inserted to the site of blockage. Once there, it is inflated and compresses the stenotic plaque that obstructs the artery, leaving a larger opening after the balloon catheter is deflated.
It is important to know that when the balloon is inflated, the circulation in the coronary is interrupted and that angina discomfort is possible.
Once the balloon is deflated, circulation resumes in this artery and the discomfort fades. Not all patients feel discomfort and some do not have any at all.
A metal spiral keeps the artery wide open
To obtain a better result in the short, medium and long term, a stent is deployed in the stenosis. A "stent" is actually a metal spiral resembling a spring that helps keep the artery wide open.
The balloon catheter brings the curled up stent to the desired location.
When the balloon inflates, the stent unfolds and presses against the walls of the vessel. The balloon is then deflated and removed, leaving the stents in place forever.
Almost all stents are coated with medications that reduce the risk of recurrence, also called restenosis, at this location.
Again, some patients may experience angina discomfort. The coronary artery may be sensitive to the stretching. The stent, once in place, dilates this artery by stretching it wide and maintains it dilated long-term.
The "stent" does not cause any rejection
There is no known rejection of stents. It is, however, a foreign body capable of stimulating platelet activity and blood coagulation, which is responsible for clot formation. A prosthesis thrombosis occurs wen the prosthesis is completely "blocked". To avoid this complication that can be fatal, precautions should be taken.
Precaution against thrombosis
The doctor prescribes a combination of medications to be taken every day to avoid thrombosis, this acute blockage of the stent.
Aspirin is given for life while the prescribed antiplatelet is given for at least a month, often a year and sometimes for life.
NEVER STOP THE ANTIPLATELET WITHOUT THE CARDIOLOGIST'S OPINION
EVEN FOR A MINOR SURGICAL INTERVENTION
Any problems with this therapy should be discussed with a physician who is well informed and completely knowledgeable in cardiology procedures, preferably a cardiologist.
The cells of the human body will completely recover in the months following the implantation.
For those who come to the hospital for en angioplasty, they may need to stay for a short hospitalisation in many hospitals. Patients usually leave early the next day.
Patients who benefit from coronary angioplasty are followed up with a healthcare professional. The angina could reappear either because of a recurrence at the place of the repair, called restenosis, or because of a new coronary lesion.
Angioplasty does not eliminate coronary heart disease. The patient must be vigilant to angina symptoms, or in other words, to discomforts appearing during an effort, relieved at rest and reappearing during the same type of effort. You must then consult your doctor.
Risk to the procedure
Coronary angioplasty is a very safe procedure, but like all medical interventions inside the body, it involves risks.
These risks are related to the medical condition of a patient as a whole and the importance of the repairs to be made.
In general, the risks of death related to this examination are evaluated at less than 1 per 1,000. Other risks of major complications such as a stroke, an infarction, kidney problems or the need for urgent surgery is assessed at less than 4 chances out of 1000.
The risks of minor complications (for example: bleeding, bruising or hematoma) are estimated at about 1%.
Read more: Coronary restenosis