Coronary Artery Disease, Angioplasty

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Coronary Artery Disease Diagnosis and Treatment:
Cardiac Catheterization and Coronary Interventional Procedures (angioplasty and stent)

Coronary artery disease is the narrowing or blockage of the coronary (heart) arteries, as shown in the top illustration. After an interventional procedure, the coronary artery is opened, increasing blood flow to the heart.

What is atherosclerosis?

Atherosclerosis (sometimes called “hardening” or “clogging” of the arteries) is the buildup of cholesterol, fatty and inflammatory deposits (called plaque) on the inner walls of the arteries that restrict blood flow to the heart. Atherosclerosis can affect the arteries in the heart, legs, brain, kidneys and other organs.

Atherosclerotic heart disease (coronary artery disease) is the narrowing or blockage of the coronary (heart) arteries. Your coronary arteries are shaped like hollow tubes through which blood can flow freely. Normally, the walls of the coronary arteries are smooth and elastic. Atherosclerosis occurs when the normal lining of the arteries deteriorates, the walls of the arteries thicken and deposits of fat and plaque build-up on the coronary artery walls, blocking or limiting the flow of oxygen-rich blood to the heart muscle.

Without adequate blood, the heart becomes starved of oxygen and the vital nutrients it needs to work properly. This can cause chest pain called angina. When one or more of the coronary arteries rapidly become blocked, a heart attack (injury to the heart muscle) may occur. Click here for more information on how coronary artery disease develops.

Cardiac catheterization

What is a cardiac catheterization?

Cardiac catheterization (also called cardiac cath or coronary angiogram) is an invasive imaging procedure that allows your doctor to evaluate your heart function. Cardiac catheterization is used to:

Evaluate or confirm the presence of coronary artery disease, valve disease or disease of the aorta
Evaluate heart muscle function
Determine the need for further treatment (such as an interventional procedure or coronary artery bypass graft, or CABG, surgery)

During a cardiac catheterization, a long, narrow tube called a catheter is inserted through a plastic introducer sheath (a short, hollow tube that is inserted into a blood vessel in your leg or arm). The catheter is guided through the blood vessel to the coronary arteries with the aid of a special x-ray machine.

Contrast material is injected through the catheter and x-ray movies are created as the contrast material moves through the heart’s chambers, valves and major vessels. This part of the procedure is called a coronary angiogram (or coronary angiography). The digital photographs of the contrast material are used to identify the site of the narrowing or blockage in the coronary artery.

Additional imaging procedures, called intravascular ultrasound (IVUS) and fractional flow reserve (FFR), may be performed along with cardiac catheterization in some cases to obtain detailed images of the walls of the blood vessels. Both are currently only available in specialized hospitals and research centers. With IVUS, a miniature sound-probe (transducer) is positioned on the tip of a coronary catheter. The catheter is threaded through the coronary arteries and, using high-frequency sound waves, produces detailed images of the inside walls of the arteries. IVUS produces an accurate picture of the location and extent of plaque. With FFR, a special wire is threaded through the artery and a vasodilator medication is given. This test is functionally performing a very high quality stress test for a short segment of the artery.

What are interventional procedures?
An interventional procedure is a non-surgical treatment used to open narrowed coronary arteries to improve blood flow to the heart. An interventional procedure can be performed during a diagnostic cardiac catheterization when a blockage is identified, or it may be scheduled after a catheterization has confirmed the presence of coronary artery disease.

An interventional procedure starts out the same way as a cardiac catheterization. Once the catheter is in place, one of these interventional procedures is performed to open the artery: balloon angioplasty, stent placement, rotoblation or cutting balloon.

balloon angioplasty

balloon is inflated to compress fatty matter

Balloon angioplasty: (Percutaneous Transluminal Coronary Angioplasty or PTCA)

A balloon angioplasty procedure in which a small balloon at the tip of the catheter is inserted near the blocked or narrowed area of the coronary artery. The technical name for balloon angioplasty is percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI). When the balloon is inflated, the fatty plaque or blockage is compressed against the artery walls and the diameter of the blood vessel is widened (dilated) to increase blood flow to the heart. This procedure is sometimes complicated by vessel recoil and restenosis.

Balloon Angioplasty and Stent

stent

stent stays in place after catheter is removed (mouse over image to see stent in place)

In most cases, balloon angioplasty is performed in combination with the stenting procedure. A stent is a small, metal mesh tube that acts as a scaffold to provide support inside the coronary artery. A balloon catheter, placed over a guide wire, is used to insert the stent into the narrowed artery. Once in place, the balloon is inflated and the stent expands to the size of the artery and holds it open. The balloon is deflated and removed, and the stent stays in place permanently. During a period of several weeks, the artery heals around the stent. In this way, restenosis is somewhat diminished.

Angioplasty with stenting is most commonly recommended for patients who have a few blockages in the coronary arteries. If there are more than a few blockages in the coronary arteries, or if the blockages are located wither stenting might be risky, coronary artery bypass graft surgery may be recommended instead of angioplasty..

A note about drug eluting stents (DES): Drug-eluting stents contain a medication that is actively released at the stent implantation site. Drug-eluting stents have a thin surface of medication to further reduce the risk of restenosis. Concern was raised in 2006 regarding the safety of drug eluting stents due to the risk of blood clots forming on the stent, causing a heart attack. The Food and Drug Administration (FDA) continues to feel that DES, when used according to approved indications, are safe and effective. [Update to FDA Statement on Coronary Drug-Eluting Stents (January 4, 2007), http://www.fda.gov/cdrh/news/010407.html*] If you receive a drug-eluting stent, your doctor will prescribe certain medications for several years after your procedure, to prevent the risk of clotting in the stent. It is extremely important to keep taking the medication until your doctor tells you otherwise. If you have concerns about drug eluting stents, please speak to your physician.

Rotablation (Percutaneous Transluminal Rotational Atherectomy or PTRA)

rotablation

tip spins at high speed to grind plaque away

For heavily calcified blockages, the Rotoblation special catheter, with an acorn-shaped, diamond-coated tip, is guided to the point of narrowing in the coronary artery. The tip spins around at a high speed and grinds away the plaque on the arterial walls. This process is repeated as needed to treat the blockage and improve blood flow. The microscopic particles are washed safely away in your blood stream and filtered out by your liver and spleen.

Cutting Balloon

cutting balloon

used with permission from Boston Scientific Corp.

The cutting balloon catheter has a balloon tip with small blades. When the balloon is inflated, the blades are activated. The small blades score the plaque, then, the balloon compresses the fatty matter into the arterial wall. This type of balloon may be used to treat the build up of plaque within a previously placed stent (restenosis) or other special types of blockages.

Are these procedures considered to be surgical procedures?
No. Cardiac catheterization and interventional procedures are not considered to be surgical procedures because there is no large incision used to open the chest, and the recovery time from catheterization is much shorter than that of surgery. In some cases, surgery may be recommended afterward, depending on the results of the procedure.

Will I be awake during the procedure?
Yes. You will be given a mild sedative to relax you, but you will be awake and conscious during the entire procedure. The doctor will use a local anesthetic to numb the catheter insertion site.

Where are the procedures performed?
The catheterization and interventional procedures are performed in the Cardiac Catheterization Laboratory.

Who performs the procedures?
Cardiac catheterization and interventional procedures are performed by a specially-trained cardiovascular invasive physician and a cardiovascular team of cardiology fellows, nurses and technicians.

How long do the procedures take to perform?
Catheterization: The actual procedure generally takes 30 minutes, but the preparation and recovery time add several hours to your appointment time (5 to 9 hours or longer). Please plan on staying at the Cleveland Clinic all day for the procedure.

Interventional procedure: An interventional procedure usually takes from 60 to 120 minutes, but the preparation and recovery time add several hours. If you had previous coronary artery bypass graft (CABG) surgery, you can expect your interventional procedure to last longer. Please plan on staying at the Cleveland Clinic all day for the procedure and remaining in the hospital overnight.

How should I prepare for the procedure?
If you need to have a cardiac catheterization or an interventional procedure, your doctor or nurse will give you specific information about what to expect before, during and after the procedure. Be sure to ask about which medications you should take beforehand.

What are the possible risks of these procedures?
If you need to have a cardiac catheterization or an interventional procedure, your cardiologist will discuss the specific risks and potential benefits of the recommended procedure with you. Some of the possible risks of cardiac catheterization and interventional procedures include:

Allergic reaction to the medication or contrast material used during the procedure
Irregular heart rhythm
Bleeding at the catheter insertion site
Chest pain or angina
Heart attack, stroke or death
Emergency coronary artery bypass graft (CABG) surgery

There may be other possible risks. When you meet with your doctor, please ask questions to make sure you understand why the procedure is recommended and what all of the potential risks are.

Does an interventional procedure cure coronary artery disease?
For most people, interventional procedures increase blood flow to the heart, diminishes chest pain and may decrease the risk of a heart attack.

Although an interventional procedure opens up blocked arteries, it does not CURE coronary artery disease. You will still need to reduce your risk factors and make certain lifestyle changes to prevent future disease development or progression.

To achieve the best results, you must be committed to leading a heart-healthy lifestyle.

Your health care team can help you achieve your goals, but it is up to you to take your medications as prescribed, make dietary changes, quit smoking, exercise regularly, keep your follow-up appointments and be an active member of the treatment team.

Cleveland Clinic Outcomes
The rate of complications associated with diagnostic cardiac catheterization at Cleveland Clinic, including heart attack, emergent CABG surgery, stroke and death was 0% in 2006. The number of patients who required emergency bypass surgery following an unsuccessful coronary intervention remained low at 0.4% in 2005 – far lower than the national average of 0.8%.

Experience is Important
Catheterization and interventional procedures require special expertise. Physician credentials and experience lead to better outcomes.

Cleveland Clinic Experience: Coronary angiography was developed at Cleveland Clinic in 1958 by F. Mason Sones, MD. The F. Mason Sones Cardiac Catheterization Laboratory features eight catheterization laboratories.

According to 2001 guidelines published by the American Heart Association in Circulation journal, hospitals should perform at least 400 percutaneous coronary interventional procedures each year.

In 2006, almost10,000 diagnostic cardiac catheterization procedures were performed at Cleveland Clinic, and over 3,000 cardiac interventional procedures were performed, including balloon angioplasty, drug- eluting stents, atherectomy and multiple restenosis treatment options.

If you want more information about interventional procedures, click here to contact us or call the Heart and Vascular Institute Resource & Information Nurse at 216/445-9288 or toll-free at 866/289-6911,. We would be happy to help you.

You may be also interested in these links:

Chronic Angina Therapy: Enhanced External Counterpulsation (EECP)
- for those who are not candidates for interventional therapies

There are a large number of patients who have persistent anginal symptoms, who have exhausted the standard treatments for revascularization and remain severely restricted. Enhanced External Counterpulsation (EECP) may stimulate the openings or formation of collaterals (small branches of blood vessels) to create a natural bypass around narrowed or blocked arteries. Read more....

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This information is provided for education purposes only and is not intended to replace the medical advice of your doctor or health care provider. While we strive to keep our website current, medical practices sometimes change quickly. Please consult your health care provider for advice about a specific medical condition or contact the Cleveland Clinic if you would like an appointment.