The first human percutaneous transluminal coronary angioplasty was developed in 1977 in Switzerland by Andreas Gruentzig. After this initial performance, this nonsurgical modality became one of the most important medical interventions for patients with coronary syndromes.

Coronary angioplasty is a procedure performed with the aim to open the blocked coronary arteries. These narrowed arteries regularly generate a syndrome known as Coronary Syndrome characterized by chest pain usually radiated to the left arm, jaw, and back.  The modern procedures involve the insertion of a medical wire to open the arteries,  as well as the introduction of the stent(a small piece of flexible metal)into the artery to keep it open.  The combination of coronary angioplasty with stent insertion is known as a Percutaneous Coronary Intervention.

Indications of the Percutaneous Coronary Intervention

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The Angioplasty intervention is a nonsurgical technique developed with the aim to treat the obstructive coronary disease.

The indications are well established according to the American Heart Association and European Society of Cardiology. Some of them are:

• Acute Myocardial infarction with ST-elevation
• Acute coronary syndrome Non–ST-elevation
• Unstable angina
• Stable angina
• Positive Stress Test findings
• Evidence of heart ischemia accompanied by unstable hemodynamic.

Different studies have revealed the positive impact of this procedure on patients with stable angina that present the following symptoms:

• severe chest pain
• a progression of the severity of the pain
• failed medical treatment
• evidence of high-risk coronary anatomy

It is essential to recognize that medical therapy is recommended as first-line therapy for patients with angina. The Angioplasty is indicated in patients with frequent angina. In cases with Acute Coronary Syndrome with no electrical changes to the ECG,  the American Heart Association recommends the performance of an Angioplasty. In these cases, the procedure can be done immediately, early or delayed.

Contraindications of the Angioplasty

The clinical contraindications of this procedure include allergy or intolerance to the antiplatelet therapy and the presence of chronic conditions like cancer.

Some cardiologist studies have revealed others contraindications relative to the angiographic findings. These contraindications include arteries with less than 1.5 mm in diameter, diffusely diseased grafts of the saphenous vein and malformations in the coronary arteries.

Percutaneous Procedure Explained

Percutaneous intervention can be performed as an elective procedure or as an urgent procedure depending on the severity of the clinical findings.

In the case of the elective intervention, the patients need to be in the hospital usually early in the morning.  The patient will be evaluated by the interventionist cardiologist who will determine medical history and perform a comprehensive physical examination. Typically, the Cardiologist may indicate some laboratory test such as complete blood count, basic metabolic profile, and coagulation profile. The ECG or electrocardiogram is frequently done before the procedure.

A dose of 325 mg of aspirin is given on the day of the procedure. If patients have a history of allergic reactions to contrast, asthma, or food allergy, prednisone is commonly indicated. Some interventionist laboratories also indicate antihistaminics.

Coronary angioplasty is done using a local anesthetic. A thin catheter will be introduced into one of the coronary arteries through an incision in the inguinal area or wrist. This process is supervised using an X-ray machine. When the catheter is in the right place, a thin wire is introduced down the length of the affected coronary artery, transporting a small balloon to the affected section of the artery. This balloon is inflated to open the artery, crushing the fatty deposits of the artery wall and as a result, the blood can flow normally when the balloon is removed. If the stent is used, it will be around the balloon before it’s inserted. The stent will extend when the balloon is expanded and remains in place when the balloon is deflated and removed.

This procedure usually takes between 30 minutes and 2 hours.

Blausen.com staff (2014). “Medical gallery of Blausen Medical 2014”. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436. [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)], from Wikimedia Commons

Complications of Coronary Angioplasty

The main limitation of balloon angioplasty is the development of acute vessel closure or vasospasm and restenosis.  The other complication is the No-reflow that happens when the artery even with the dispositive or stent inside is unable to open due to the atherosclerotic changes.  Other complications are bleeding on the puncture site, infection, and bacterial endocarditis.

Postoperative Management and Rehabilitation

The management and the postoperative treatment will depend on the presentation of the symptoms and how the procedure was performed. If the patient was treated for angina, he or she might be able to be discharged from the hospital the following day after the procedure.  If the patient was presenting an acute coronary syndrome, he/she will need to stay in-hospital for a longer period of time.

Frequently after the procedure, the patient needs to take blood-thinning medications for up to 1 year. Usually, this medication is a combination of P2Y12 receptor inhibitor (clopidogrel, prasugrel, or ticagrelor) and aspirin. This combination is known as an Antiplatelet therapy. The duration of therapy will depend on the type of procedure and the characteristics of the lesion already evaluated in the coronary arteries

The Glycoprotein inhibitor therapy is another option of treatment.  This therapy includes some medications such as abciximab, tirofiban, and eptifibatide with the aim to reduce the possible ischemic complications in patients with balloon angioplasty and stent.

Cardiac rehabilitation is an essential step during the recovery process.  The cardiac rehabilitation programme will begin in the hospital, and it will continue 4 to 8 weeks after discharge from the hospital.

The patients also need to make some changes in the lifestyle such as lose weight, to avoid toxic habits like smoking or drinking alcohol, to keep a healthy diet, to practice exercises.

Other elements that the patients need to take into consideration are: to avoid heavy lifting and demanding activities for about a week, or until the wound has recovered, and to avoid driving a car for at least a week

Patient undergoing an elective coronary angioplasty should be able to return to work after a week. But patients undergoing emergency angioplasty following a heart attack will have to wait several weeks or months before being able to get back to normal activities.

References

1. What Is Coronary Angioplasty? – American Heart Association. https://www.heart.org/-/media/data-import/downloadables/pe-abh-what-is-coronary-angioplasty-ucm_300437.pdf
2. Stable Coronary Artery Disease (Management of) ESC Clinical Practice Guidelines https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Stable-Coronary-Artery-Disease-Management-of
3. Dundar Y, Hill R A, Bakhai A, Dickson R, Walley T.  Angioplasty and stents in coronary artery disease: a systematic review and meta-analysis. Scandinavian Cardiovascular Journal 2004; 38(4): 200-210. [PubMed: 15553930
4. Hill RA, Dundar Y, Dickson R, Walley T. Percutaneous transluminal coronary angioplasty with stents versus coronary artery bypass grafting for people with stable angina or acute coronary syndromes. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD004588.
5. Byrne RA, Stone GW, Ormiston J, Kastrati A. Coronary balloon angioplasty, stents, and scaffolds. Lancet. 2017 Aug 19;390(10096):781-792. doi: 10.1016/S0140-6736(17)31927-X.
6. Tienush Rassaf, Stephan Steiner, and Malte Kelm. Postoperative Care and Follow-Up After Coronary Stenting. Dtsch Arztebl Int. 2013 Feb; 110(5): 72–82. doi : 10.3238/arztebl.2013.0072

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