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July 2012
STENTING
Opening The Pathways
Dr P K Sahoo
 
Coronary angioplasty or stenting is a procedure used to open narrow or blocked coronary heart arteries. The procedure restores blood flow to the heart muscle. The blockage in the arteries are a result of the buildup or formation of cholesterol-laden plaques due to atherosclerosis.

Coronary angioplasty is usually performed by an interventional cardiologist, a doctor specialised in the treatment of the heart using invasive catheter-based procedures.

Where Coronary Angioplasty/Stenting Is Indicated?
  • Cases of chest pain – acute or chronic (angina), proved to have single or multiple discreet blocks on an angiogram.
  • Patients having positive treadmill tests and demonstrable blocks on angiogram.
  • Post ‘heart attacks’ where angiogram shows residual blocks after the use of clot busting drugs.
  • Post ‘bypass surgery’ cases who develop fresh blocks and are not considered fit for a re-do surgery.
  • Patients with borderline blocks having positive ‘myocardial perfusion studies’.
When Not To Go For Coronary Angioplasty/Stenting
  • Left main stenosis in a patient who is a surgical candidate. (Although bypass surgery is still the preferred treatment for left main stenosis, this area is rapidly evolving toward safe and feasible angioplasty options.)
  • Diffusely diseased small-caliber artery.
  • Multiple blocks, especially in diabetic patients, where bypass surgery has better outcome.
How Is It Done?
  • A long flexible soft plastic tube called guiding catheter is pushed through the femoral artery in the leg or the radial artery to reach to the coronary artery. The tip of the guiding catheter is placed at the mouth of the coronary artery.
  • The guiding catheter allows for radioopaque dyes (usually iodine based) to be injected into the coronary artery, so that the disease state and location can be readily assessed using x-ray visualization.
  • The guidewire acts as the pathway to the stenosis. The tip of the angioplasty or balloon catheter is hollow and is then inserted at the back of the guidewire—thus the guidewire is now inside of the angioplasty catheter.
  • The balloon is then inflated, and it compresses the atheromatous plaque and stretches the artery wall to expand.
How Safe Is The Procedure?
In the hands of experienced cardiologists, and with availability of modern day technology, it is estimated that the risk of death during an angioplasty procedure is usually less than one per cent, while the chance of requiring emergency bypass surgery is rare. It is a relatively safe procedure and is carried out all over the world. An “outpatient” or an “inpatient” uncomplicated angioplasty usually requires 24-48 hours or less of hospitalization after the procedure. Primary angioplasty should be undertaken in centres where the workload of routine coronary angioplasties is more than 200 elective cases per year.

Risks Of The Procedure
  • Bleeding at the catheter insertion site
  • Blood clot or damage to the blood vessel at the insertion site
  • Blood clot within the vessel treated by PTCA/stent
  • Infection at the catheter insertion site
  • Cardiac dysrhythmias/arrhythmias (abnormal heart rhythms)
  • Myocardial infarction
  • Chest pain or discomfort
  • Rupture of the coronary artery, requiring open-heart surgery
Choosing Stents – BMS (Bare metal stents) or DES (Drug eluting stents)
Results with use of DES have been shown to have better long term outcomes. However, there are chances of increased clotting with DES. So, antiplatelets (blood thinners) have to be used in higher doses and longer periods with implantation of DES. For diabetic patients, and patients with small vessels, long segment blocks or multiple blocks, it is wise to choose an FDA approved DES. Non diabetics , patients with large vessels, elderly individuals (in whom blood thinners may be risky to administer for long) should choose BMS.
Dr P K Sahoo is Senior Consultant Interventional Cardiologist Apollo Hospitals,Bhubaneshwar.

    
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