Overview-Coronary angioplasty and stent insertion
A coronary angioplasty is a procedure used to widen blocked or narrowed coronary arteries (the main blood vessels supplying the heart).
The term "angioplasty" means using a balloon to stretch open a narrowed or blocked artery. However, most modern angioplasty procedures also involve inserting a short wire-mesh tube, called a stent, into the artery during the procedure. The stent is left in place permanently to allow blood to flow more freely.
Coronary angioplasty is sometimes known as percutaneous transluminal coronary angioplasty (PTCA). The combination of coronary angioplasty with stenting is usually referred to as percutaneous coronary intervention (PCI).
When a coronary angioplasty is used
Like all organs in the body, the heart needs a constant supply of blood. This is supplied by the coronary arteries.
In older people, these arteries can become narrowed and hardened (known as atherosclerosis), which can cause coronary heart disease.
If the flow of blood to the heart becomes restricted, it can lead to chest pain known as angina, which is usually triggered by physical activity or stress.
While angina can often be treated with medication, a coronary angioplasty may be required to restore the blood supply to the heart in severe cases where medication is ineffective.
Coronary angioplasties are also often used as an emergency treatment after a heart attack.
What are the benefits of a coronary angioplasty?
In most cases, the blood flow through the coronary arteries improves after an angioplasty. Many people find their symptoms get significantly better and they're able to do more than they could before the procedure.
If you've had a heart attack, an angioplasty can increase your chances of surviving more than clot-busting medication (thrombolysis). The procedure can also reduce your chances of having another heart attack in the future.
How a coronary angioplasty is performed
A coronary angioplasty is performed using local anaesthetic, which means you'll be awake while the procedure is carried out.
A thin flexible tube called a catheter will be inserted into one of your arteries through an incision in your groin, wrist or arm. This is guided to the affected coronary artery using an X-ray video.
When the catheter is in place, a thin wire is guided down the length of the affected coronary artery, delivering a small balloon to the affected section of artery. This is then inflated to widen the artery, squashing fatty deposits against the artery wall so blood can flow through it more freely when the deflated balloon is removed.
If a stent is being used, this will be around the balloon before it's inserted. The stent will expand when the balloon is inflated and remains in place when the balloon is deflated and removed.
A coronary angioplasty usually takes between 30 minutes and 2 hours. If you're being treated for angina, you'll normally be able to go home later the same day or the day after you have the procedure. You'll need to avoid heavy lifting, strenuous activities and driving for at least a week.
If you've been admitted to hospital following a heart attack, you may need to stay in hospital for several days after the angioplasty procedure before going home.
How safe is a coronary angioplasty?
A coronary angioplasty is 1 of the most common types of treatment for the heart.
Coronary angioplasties are most commonly performed in people aged 65 or older, as they're more likely to have heart disease.
As the procedure doesn't involve making major incisions in the body, it's usually carried out safely in most people. Doctors refer to this as a minimally invasive form of treatment.
The risk of serious complications from a coronary angioplasty is generally small, but this depends on factors such as:
- your age
- your general health
- whether you've had a heart attack
Serious problems that can occur as a result of the procedure include:
- excessive bleeding
- a heart attack
- a stroke
Are there any alternatives?
If many coronary arteries have become blocked and narrowed, or the structure of your arteries is abnormal, a coronary artery bypass graft may be considered.
This is a type of invasive surgery where sections of healthy blood vessel are taken from other parts of the body and attached to the coronary arteries. Blood is diverted through these vessels, so it bypasses the narrowed or clogged parts of the arteries.
How it's performed-Coronary angioplasty and stent insertion
Before having a coronary angioplasty you'll need an assessment to make sure the operation is possible.
This also gives you an opportunity to discuss any concerns with your cardiologist (heart specialist).
During your pre-operative assessment, you may have blood tests and a general health check to ensure you're suitable for surgery.
You may also have a procedure called an angiogram before your angioplasty. You have the angiogram first to look inside your arteries to check where the blockages are.
Sometimes your cardiologist will do the angiogram first but then continue on to do the angioplasty as part of the same procedure.
You'll be asked not to eat or drink anything for 4 to 6 hours before a coronary angioplasty.
You'll usually be able to take most medications as normal up to the day of the procedure, with the exception of blood-thinning medication (anticoagulants), such as warfarin.
You may also need to alter the timing of any diabetes medication you take.
Speak to your medical team for more information about whether you need to change the way you take your medicines before your operation.
The operation
A coronary angioplasty usually takes place in a room called a catheterisation laboratory, rather than in an operating theatre. This is a room fitted with X-ray equipment to allow the doctor to monitor the procedure on a screen.
A coronary angioplasty usually takes between 30 minutes and 2 hours, although it can take longer.
You'll be asked to lie on your back on an X-ray table. You'll be linked up to a heart monitor and given a local anaesthetic to numb your skin. An intravenous (IV) line will also be inserted into a vein, in case you need to have painkillers or a sedative.
The cardiologist then makes a small incision in the skin of your groin, wrist or arm, over an artery where your pulse can be felt. A small tube called a sheath is inserted into the artery to keep it open during the procedure.
A catheter is passed through the sheath and guided along the artery into the opening of your left or right coronary artery.
A thin, flexible wire is then passed down the inside of the catheter to beyond the narrowed area. A small, sausage-shaped balloon is passed over the wire to the narrowed area and inflated for about 20 to 30 seconds. This squashes the fatty material on the inside walls of the artery to widen it. This may be done several times.
While the balloon is inflated, the artery will be completely blocked and you may have some chest pain. However, this is normal and is nothing to worry about. The pain should go away when the balloon is deflated. Ask your cardiologist for pain medication if you find it uncomfortable.
You shouldn't feel anything else as the catheter moves through the artery, but you may feel an occasional missed or extra heartbeat. This is nothing to worry about and is completely normal.
If you're having a stent inserted (see below), it will be already fitted onto a balloon and opens up as the balloon is inflated. The stent will be left inside your artery after the balloon is deflated and removed.
When the operation is finished, the cardiologist will check that your artery is wide enough to allow blood to flow through more easily. This is done by monitoring a small amount of contrast dye as it flows through the artery.
The balloon, wire, catheter and sheath are then removed and any bleeding is stopped with a dissolvable plug or firm pressure. In some cases, the sheath is left in place for a few hours or overnight before being removed.
Going home
A coronary angioplasty often involves an overnight stay in hospital, but many people can go home on the same day if the procedure is straightforward.
After the operation, you won't be able to drive for 1 week, so you'll need to arrange for someone to drive you home from hospital.
Stents
A stent is a short, wire-mesh tube that acts like a scaffold to help keep your artery open. There are 2 main types of stent:
- bare metal (uncoated) stent
- drug-eluting stent – which is coated with medication that reduces the risk of the artery becoming blocked again
The biggest drawback of using bare metal stents is that, in some cases, the arteries begin to narrow again. This is because the immune system sees the stent as a foreign body and attacks it, causing swelling and excessive tissue growth around the stent.
It's possible to avoid this problem by using drug-eluting stents. These are coated with medication that reduces the body’s abnormal response and tissue growth. However, this also delays the healing of the coronary artery around the stent and means it's vitally important to keep taking blood thinning treatment for up to 1 year after the procedure. This helps reduce the risk of a blood clot blocking the stent suddenly and causing a heart attack.
Once a drug-eluting stent is in place, the medication is released over time into the area most likely to become blocked again. The 2 most researched types of medication are:
- "-limus" medications (such as sirolimus, everolimus and zotarolimus) – which have previously been used to prevent rejection in organ transplants
- paclitaxel – which inhibits cell growth and is commonly used in chemotherapy
The National Institute for Health and Care Excellence (NICE) recommends that drug-eluting stents should be considered if the artery being treated is less than 3mm in diameter or the affected section of the artery is longer than 15mm, because evidence suggests the risk of re-narrowing is highest in these cases.
Before your procedure, discuss the benefits and risks of each type of stent with your cardiologist.
If you have a stent, you'll also need to take certain medications to help reduce the risk of blood clots forming around the stent. These include:
- aspirin – taken every morning for life
- clopidogrel – taken for 1 to 12 months depending on whether you have had a bare metal or drug-eluting stent, or whether you have had a heart attack
- prasugrel or ticagrelor – used as alternatives to clopidogrel in people who have been treated for a heart attack
Deciding where to get treatment
You can choose where to have your treatment. Ask your GP if they can recommend a hospital with experienced cardiology staff who perform large numbers of angioplasties each year. The cardiologist that carries out the procedure is a specialist known as an "interventional cardiologist".
Recovery-Coronary angioplasty and stent insertion
After having a planned (non-emergency) coronary angioplasty, you'll normally be able to leave hospital the same day or following day. Arrange for someone to take you home.
Before you leave hospital, you should be given advice on:
- any medication you need to take (see below)
- improving your diet and lifestyle
- wound care and hygiene advice during your recovery
You may also be given a date for a follow-up appointment to check on your progress.
You may have a bruise under the skin where the catheter was inserted. This isn't serious, but it may be sore for a few days. Occasionally, the wound can become infected. Keep an eye on it to check it's healing properly.
Your chest may also feel tender after the procedure, but this is normal and usually passes in a few days. If necessary, you can take paracetamol to relieve any pain.
Activities
Your hospital team can usually advise you about how long it will take to recover and if there are any activities you need to avoid in the meantime.
In most cases, you'll be advised to avoid heavy lifting and strenuous activities for about a week, or until the wound has healed.
Driving
You shouldn't drive a car for a week after having a coronary angioplasty.
If you drive a heavy vehicle for a living, such as a lorry or a bus, you must inform the DVLA that you've had a coronary angioplasty. They'll arrange further testing before you can return to work.
You should be able to drive again as long as you meet the requirements of an exercise/function test and you don't have another disqualifying health condition.
GOV.UK has more information on coronary angioplasty and driving.
Work
If you had a planned (non-emergency) coronary angioplasty, you should be able to return to work after a week.
However, if you've had an emergency angioplasty following a heart attack, it may be several weeks or months before you recover fully and are able to return to work.
Sex
If your sex life was previously affected by angina, you may be able to have a more active sex life as soon as you feel ready after a coronary angioplasty.
If you have any concerns, speak to your GP. According to experts, having sex is the equivalent of climbing a couple of flights of stairs in terms of the strain it puts on your heart.
Medication and further treatment
Most people need to take blood-thinning medications for up to 1 year after having an angioplasty. This is usually a combination of low-dose aspirin and one of the following medications:
- clopidogrel
- prasugrel
- ticagrelor
It's very important you follow your medication schedule. If you stop your medication early, it greatly increases your risk of a heart attack caused by the treated artery becoming blocked.
The course of clopidogrel, prasugrel or ticagrelor will usually be withdrawn after about a year, but most people need to continue taking low-dose aspirin for the rest of their life.
You may need to have another angioplasty if your artery becomes blocked again and your angina symptoms return. Alternatively, you may need a coronary artery bypass graft (CABG).
Cardiac rehabilitation
Cardiac rehabilitation should be offered if you've had a heart operation. This programme aims to help you recover from the procedure and get back to everyday life as quickly as possible.
Your cardiac rehabilitation programme will begin when you're in hospital. You should also be invited back for another session taking place within about 4 to 8 weeks after you leave hospital.
A member of the cardiac rehabilitation team will visit you in hospital and provide detailed information about:
- your state of health
- the type of treatment you received
- what medications you'll need when you leave hospital
- what specific risk factors are thought to have contributed to needing the operation
- what lifestyle changes you can make to address those risk factors
Once you've completed your rehabilitation programme, it's important you continue to take regular exercise and lead a healthy lifestyle (see below). This helps protect your heart and reduce the risk of further heart-related problems.
The British Heart Foundation has more information about cardiac rehabilitation.
Lifestyle changes
If you have a coronary angioplasty, it's still important to take steps to reduce your risk of having further problems in the future. This may include:
- trying to lose weight if you're overweight
- stopping smoking if you smoke
- eating a healthy diet with low levels of fat and salt
- being active and exercising regularly
Smoking and being overweight are 2 of the main causes of heart disease. They also make treatment less likely to work.
When to seek medical advice
You should contact the hospital unit where the procedure was carried out, your specialist cardiac nurse, or your GP for advice if you develop:
- a hard, tender lump (larger than the size of a pea) under the skin around your wound
- increasing pain, swelling and redness around your wound
- a high temperature (fever)
Dial 999 for an ambulance – do not drive yourself – if you experience:
- any bleeding from your wound that doesn't stop or restarts after applying pressure for 10 minutes
- severe chest pain that doesn't ease – if you have been prescribed medicine for angina try taking this, but if it doesn't help then seek urgent help
- discolouration, coldness or numbness in the leg or arm where the incision was made
Risks-Coronary angioplasty and stent insertion
As with all types of surgery, coronary angioplasty carries a risk of complications. However, the risk of serious problems is small.
Complications can occur during or after an angioplasty.
It's common to have bleeding or bruising under the skin where the catheter was inserted.
More serious complications are less common but can include:
- damage to the artery where the sheath was inserted
- allergic reaction to the contrast agent used during the procedure
- damage to an artery in the heart
- excessive bleeding requiring a blood transfusion
- heart attack, stroke or death
Who's most at risk?
Several factors increase your risk of experiencing these complications. These include:
- your age – the older you are, the higher the risk
- whether the procedure was planned (for angina), or is emergency treatment for or after a heart attack – emergency treatment is always riskier because there's less time to plan it and the patient is already unwell
- whether you have kidney disease – the contrast agent used during an angioplasty can occasionally cause further damage to the kidneys
- whether more than 1 coronary artery has become blocked – this is known as multi-vessel disease
- whether you have a history of serious heart disease, including heart failure
Your cardiology team can give you more information about your individual circumstances and level of risk.
Alternatives-Coronary angioplasty and stent insertion
The most widely used surgical alternative to a coronary angioplasty is a coronary artery bypass graft (CABG).
Coronary artery bypass graft
A coronary artery bypass graft is surgery to bypass a blockage in an artery. This is done using segments of healthy blood vessel, called grafts, taken from other parts of the body.
Segments of vein or artery from your legs, arms or chest are used to create a new channel through which blood can be directed past the blocked part of the artery. This allows more blood to get through into the heart muscle.
Complications of CABG are uncommon, but are potentially serious. They include:
- a heart attack
- a stroke
A CABG is usually recommended when multiple coronary arteries have become blocked and narrowed. However, it's invasive surgery so may not be suitable for people who are particularly frail and in poor health.
A CABG may also be used if the anatomy of the blood vessels near your heart is abnormal because a coronary angioplasty may not be possible in these cases.
Which procedure is best?
You may not always be able to choose between having a coronary angioplasty or a CABG, but if you are it's important to be aware of the advantages and disadvantages of each technique.
As a coronary angioplasty is minimally invasive, you'll recover from the effects of the operation quicker than you will from a CABG. Coronary angioplasty usually has a smaller risk of complications, but there's a chance you'll need further treatment because the affected artery may narrow again.
However, the number of people who need further surgery has fallen because of the use of drug-eluting stents – which are coated with medication that reduces the risk of the artery becoming blocked again. See how a coronary angioplasty is performed for more information about these.
CABG has a longer recovery time than coronary angioplasty and a higher risk of complications. But, some evidence suggests that CABG is usually a more effective treatment option for people who are over 65 years of age and particularly for people with diabetes.
You should discuss the benefits and risks of both types of treatment with your cardiologist and cardiac surgeon before making a decision.
Alternative types of coronary angioplasty
If a conventional coronary angioplasty is unsuitable because the fatty deposits in your coronary arteries are very hard, you may be offered a different type of angioplasty procedure that involves destroying or cutting away these deposits.
Examples of this type of procedure include:
- percutaneous transluminal coronary rotational atherectomy (PTCRA) – where a small rotating device is used to remove the fatty deposit
- percutaneous laser coronary angioplasty – where a laser is used to burn through the fatty deposit
These procedures are usually used when the coronary artery has a high level of calcium in it. Calcium makes the artery very hard and can prevent balloons or stents expanding properly to relieve the narrowing.
Once the deposit has been removed, the artery is treated with balloons and stents as during a conventional angioplasty procedure.