Coronary Angioplasty & Stenting

Coronary angioplasty and stenting is a procedure that opens a narrowed or blocked artery in the heart by threading a tiny balloon into the vessel, inflating it to widen the passage, and then placing a small metal mesh tube called a stent to hold the artery open.

The heart muscle needs a steady supply of oxygen-rich blood through the coronary arteries (the arteries that wrap around the outside of the heart). Over time, fatty deposits called plaque can build up inside these arteries, making them narrow and stiff. When blood flow is reduced or cut off, the heart muscle is starved of oxygen. During angioplasty, a cardiologist (heart specialist) guides a thin, flexible tube called a catheter through a blood vessel — usually starting from the wrist or groin — up to the blocked coronary artery. A balloon on the tip of the catheter is inflated to push the plaque against the artery wall and restore blood flow. The stent, which is crimped onto the balloon beforehand, expands with it and stays in place permanently, acting like a scaffold to keep the artery open.

This procedure is used when one or more coronary arteries are significantly narrowed or blocked, causing reduced blood flow to the heart. Doctors recommend it when the narrowing is severe enough to cause symptoms or to put the heart at serious risk.

• Stable angina (chest pain or tightness that occurs predictably during exertion and is not improving with medication alone)
• Unstable angina (chest pain that occurs at rest or is getting worse — a warning sign that a heart attack may be close)
• NSTEMI — non-ST-elevation myocardial infarction (a type of heart attack where partial blockage cuts off blood flow to part of the heart muscle)
• STEMI — ST-elevation myocardial infarction (a major heart attack caused by a complete blockage of a coronary artery, where angioplasty is the preferred emergency treatment to restore blood flow as quickly as possible)
• Restenosis (re-narrowing of a coronary artery that was previously treated with angioplasty or a stent)
• Significant coronary artery narrowing found on imaging tests such as a coronary angiogram (an X-ray picture of the heart's arteries) or CT coronary angiography

Coronary angioplasty is not always the right choice. Doctors will usually recommend coronary artery bypass surgery (open-heart surgery that reroutes blood around blocked arteries) instead when:

• Multiple arteries are severely blocked in a complex pattern that is difficult to treat with a catheter
• The left main coronary artery (the main trunk supplying the majority of the heart muscle) is blocked and the anatomy makes stenting risky
• The patient has diabetes with widespread coronary artery disease affecting many vessels
• A previous angioplasty has failed or restenosis has occurred repeatedly
• The overall heart function is significantly reduced and bypass surgery offers better long-term benefit

Coronary angioplasty and stenting is generally considered a safe and well-established procedure, but like any intervention inside the heart and blood vessels, it carries recognised risks that the medical team will discuss with the patient beforehand.

• Bleeding or bruising at the catheter entry site (wrist or groin), which is the most common side effect and usually minor
• Damage to the blood vessel at the entry site, including small tears in the artery wall
• Re-narrowing of the treated artery (restenosis), which can happen weeks to months after the procedure, particularly with bare-metal stents; drug-eluting stents (stents coated with medication to slow cell growth) reduce but do not eliminate this risk
• Blood clot forming inside the stent (stent thrombosis), a rare but serious complication that can cause a heart attack; this is why doctors prescribe blood thinners after the procedure
• Heart attack occurring during or shortly after the procedure, usually from a clot or artery spasm (sudden tightening of the artery wall)
• Arrhythmia (an irregular heartbeat) during the procedure, which the team monitors for and can treat immediately
• Kidney stress from the contrast dye (a special liquid injected to make arteries visible on X-ray), particularly in patients with existing kidney problems
• Allergic reaction to the contrast dye, ranging from mild skin flushing to, rarely, a more serious reaction
• Stroke, a rare but recognised risk when a small piece of plaque or a clot is dislodged and travels to the brain
• Rarely, emergency open-heart surgery may be needed if a serious complication occurs during the procedure that cannot be managed with the catheter

Preparation usually begins in the days before the procedure and continues on the day itself. The exact instructions will depend on whether the angioplasty is planned in advance (elective) or performed as an emergency. For a planned procedure, the care team will give specific guidance — the points below describe what typically happens.

Before the procedure, patients are usually asked to:

• Fast (avoid all food and drink, including water) for several hours beforehand — the team will specify how long
• Continue or pause certain regular medications, especially blood thinners or diabetes medications; the cardiologist will give clear instructions for each drug
• Avoid smoking in the days leading up to the procedure, as smoking affects blood vessel function and healing
• Avoid alcohol for at least a day or two beforehand
• Report any known allergies, especially to iodine or contrast dye, shellfish, or latex
• Inform the team about all medications, supplements, and herbal remedies being taken

Before the procedure, the hospital team typically runs a set of preparatory tests, which may include:

• Blood tests to check kidney function (important because of the contrast dye), blood clotting ability, and general health
• An EKG (electrocardiogram — a recording of the heart's electrical activity) to check heart rhythm
• A chest X-ray to see the size and shape of the heart and lungs
• An echocardiogram (heart ultrasound using sound waves to show how the heart muscle is pumping) in some cases
• A coronary angiogram (an X-ray-based imaging test of the coronary arteries) if not already done — this is sometimes performed in the same session immediately before angioplasty

On the day of the procedure, here is what typically happens, step by step:

• The patient changes into a hospital gown and lies on a padded table in a catheterisation laboratory (a specialised room with X-ray equipment, commonly called a cath lab)
• Electrodes (small sticky patches) are placed on the chest to monitor the heart rhythm continuously throughout
• An intravenous (IV) line is placed in a vein in the arm to deliver fluids and medications during the procedure
• The skin at the entry site — usually the wrist (radial approach) or the groin (femoral approach) — is cleaned and a local anaesthetic (numbing injection) is given so the patient feels pressure but not sharp pain
• A thin plastic sheath (introducer sheath) is inserted into the artery at that site to create a stable access point
• The cardiologist threads a guidewire — a very thin, flexible wire — through the sheath and navigates it to the coronary artery using live X-ray images (fluoroscopy) on a screen above the table
• Contrast dye is injected through the catheter so the artery and the blockage are clearly visible on the X-ray screen
• The balloon catheter is advanced over the guidewire to the site of the blockage, and the balloon is inflated for a short time to compress the plaque and widen the artery
• The stent, which is mounted on the balloon, expands with it and locks into position against the artery wall; the balloon is then deflated and withdrawn, leaving the stent in place
• The cardiologist injects more contrast dye to confirm that blood is flowing freely through the newly opened artery
• The sheath is removed from the wrist or groin and firm pressure or a small closure device is used to stop the bleeding at the entry site
• The patient is moved to a recovery or monitoring area; the total time in the cath lab varies — straightforward cases may take less than an hour, more complex cases take longer

After the procedure, the patient is moved to a monitored recovery area — often a cardiac care unit — where the heart rhythm, blood pressure, and the entry site are checked regularly. Most patients who have a planned (elective) angioplasty stay in hospital for one night; those treated during an emergency heart attack may stay longer depending on their condition. Recovery at home is usually faster than after open-heart surgery, but it is important to follow the care team's guidance carefully, especially regarding medications.

• Dual antiplatelet therapy (two types of blood thinners taken together to prevent clots forming inside the stent) is typically prescribed for a period of months — the exact duration depends on the type of stent used and the individual patient's situation; stopping these medications early without medical advice can be dangerous
• The entry site (wrist or groin) should be kept clean and dry; the team will explain how to care for it and what signs of infection — such as increasing redness, warmth, swelling, or discharge — to watch for
• Heavy lifting and strenuous physical activity are usually restricted for at least a week after the procedure; the care team will advise when it is safe to gradually return to normal activities
• Driving is typically not permitted for a short period after the procedure; specific guidance depends on local regulations and the individual's condition
• Returning to work depends on the nature of the job and how the patient feels; desk work is usually possible sooner than physically demanding work
• A cardiac rehabilitation programme (a structured programme of supervised exercise, education, and lifestyle support) is often recommended to help the heart recover and reduce the risk of future problems
• Lifestyle changes are an important part of long-term care: a heart-healthy diet, regular moderate exercise, quitting smoking, managing blood pressure, controlling cholesterol (fatty substances in the blood), and managing blood sugar in patients with diabetes
• Follow-up appointments are typically scheduled within weeks of the procedure to review the EKG, check blood tests, and assess how the patient is feeling; imaging tests may be repeated if symptoms return