Coronary angioplasty and stents

What is coronary angioplasty?

Coronary angioplasty, also called percutaneous coronary intervention (PCI), treats narrowings in the arteries that supply the heart. A fine wire is passed across the narrowing, a balloon widens it, and a stent is left in place to hold the artery open.

A stent is a small mesh tube, usually made of cobalt-chromium or platinum-chromium. Modern stents are drug-eluting: they slowly release a medicine that stops scar tissue growing back inside the stent. Over a few months, the artery lining grows over the stent so that it becomes part of the vessel wall.

Angioplasty is usually done during or after a coronary angiogram, which shows where the narrowings are.

Who benefits?

If you have narrowings in several arteries, bypass surgery may be a better option. In those cases your scans are discussed in a heart team meeting with cardiac surgeons, so you receive a balanced recommendation.

How it is done

1. Access. Local anaesthetic is given at the wrist, and a thin tube is passed up to the heart. You are awake throughout, with light sedation if you wish.
2. Assessment. X-ray pictures with contrast dye show the narrowing. A pressure wire can confirm whether a borderline narrowing is significant, and imaging from inside the artery shows the plaque in detail.
3. Crossing the narrowing. A very fine guidewire is steered across the narrowing.
4. Preparing the artery. Balloons widen the narrowing. Hard, calcified plaque may need specialist treatment first (see below).
5. Stenting. The stent is positioned and expanded with a balloon, pressing it firmly against the artery wall. Its size and expansion are checked with imaging.

A straightforward procedure takes around 30 to 60 minutes. Many people go home the same day; others stay one night.

Imaging-guided PCI

X-ray pictures show only a silhouette of the artery. Intravascular imaging places a tiny camera inside the artery to show the vessel wall and plaque directly:

• Intravascular ultrasound (IVUS): uses sound waves to measure the artery and see through deep plaque.
• Optical coherence tomography (OCT): uses light to give very high-resolution images of the artery lining and stent.

Imaging helps choose the right stent size, confirms the stent is fully expanded and well positioned, and identifies problems that X-ray alone can miss. Randomised trials have shown that imaging guidance reduces the need for repeat procedures, particularly in long or complex narrowings. I use intravascular imaging routinely in complex cases.

Calcified and complex arteries

Over time, plaque can harden with calcium, a bit like bone. A heavily calcified artery can be impossible to widen with a balloon alone, and a stent placed without proper preparation may not expand fully. Specialist calcium modification techniques break up or remove the calcium first:

The choice of technique depends on how much calcium there is, where it lies in the artery wall, and the shape of the vessel. Intravascular imaging is used to make that choice and to check the result. I also contribute patients to the British Orbital Atherectomy Registry, which tracks real-world outcomes of orbital atherectomy.

Other complex situations include narrowings at branch points, long diffuse disease, previous bypass surgery and completely blocked arteries (chronic total occlusions). These procedures take longer and carry somewhat higher risks, which are discussed with you in detail beforehand.

Risks

Planned angioplasty is a common and generally safe procedure. Serious complications, including heart attack, stroke, the need for emergency surgery or death, occur in around 1 in 100 planned procedures, and less often in straightforward cases. Your individual risk is discussed with you beforehand. Complex procedures carry a higher risk.

Other possible problems include:

• bruising or bleeding at the wrist
• damage to the artery, such as a tear, which is usually treated with an additional stent during the procedure
• an allergic reaction to the contrast dye
• strain on the kidneys from the dye
• re-narrowing or clotting of the stent later on (see below)

Medicines after a stent

After a stent you will take two antiplatelet medicines, usually aspirin plus clopidogrel, ticagrelor or prasugrel. This is usually for 6 to 12 months, followed by one antiplatelet long term. The exact duration depends on why the stent was placed and your risk of bleeding.

You will also usually take a statin and other medicines to protect your heart and reduce the chance of new narrowings developing.

Recovery

• Driving: DVLA guidance for car and motorcycle licences is not to drive for at least one week after a successful planned angioplasty. You do not need to tell the DVLA. Bus and lorry licence holders must notify the DVLA.
• Work: most people return to desk-based work within about a week. Manual jobs may need longer.
• Exercise: avoid heavy lifting with the treated arm for about a week, then build up activity gradually. Cardiac rehabilitation is recommended.
• Flying: usually possible within a few days of an uncomplicated planned procedure. Inform your travel insurer.
• Follow-up: a clinic review to check your symptoms and medicines.

Fees and insurance

Most UK private medical insurers cover coronary angioplasty when it is clinically indicated. Please obtain pre-authorisation before the procedure. For self-funding patients, a written quote covering hospital and consultant fees is provided before you go ahead, as the cost depends on the number of stents and any specialist equipment needed.

Where: [Royal Papworth Hospital private patients unit — confirm]