Coronary Angioplasty (PCI)
What is this?
Coronary angioplasty, often known as PCI (Percutaneous Coronary Intervention), is a method of improving blood flow to the heart muscle by opening narrowed areas in the coronary arteries. It is a “keyhole” technique that involves a small puncture in the skin rather than a big operation. Usually a stent is implanted to hold the artery open.
What does it involve?
The patient is asked to starve overnight and is usually admitted to hospital on the morning of the test. Routine blood tests are taken, looking particularly for abnormalities of blood clotting and kidney function. The procedure takes place in the Cardiac Catheter Laboratory with the patient awake but often under sedation and continually monitored. A fine tube called a catheter is inserted into an artery usually in the leg or the wrist under local anaesthetic. The tube is passed up to the coronary arteries and the cardiologist manoeuvres the tip into the correct position using X-ray guidance and injections of a special dye or contrast agent that opacifies the arteries during X-ray exposure. A second, thinner ‘balloon’ catheter is passed down this tube over a guide wire and, when in position, is inflated to squash the atheroma outwards and widen the narrowed artery. While the balloon is inflated blood flow down the artery is briefly interrupted and the patient may feel some angina pain. This usually resolves when the balloon is deflated after a few seconds. A stent mounted on a similar balloon catheter is usually then deployed in a similar manner to hold the artery open. Stents are made from a stainless steel mesh and look a bit like the spring in a ballpoint pen. They are crimped onto a deflated balloon which is then inflated when in position to deploy the stent at the site of the narrowing in the artery. Several narrowed areas in the coronary arteries may be treated during the same procedure using several stents. After the intervention the catheter is removed and pressure is applied to the puncture site to stop bleeding or a special collagen plug inserted. The patient will receive additional medication for a period to optimise blood flow through the stent, and they will usually be advised to stay in hospital overnight.
Who might require Coronary Angioplasty?
If an acute heart attack is diagnosed on ECG, the patient may be offered angioplasty as an alternative to the more commonly used “clot busting” medication. “Primary Angioplasty” is felt to be a superior treatment for an acute heart attack and although it is not available everywhere in the country, it is becoming more common. It can also be used in situations where blood thinning medication cannot be used, or where it has failed to work.
Where a heart attack is diagnosed on blood tests, without the typical ECG changes, angioplasty may be considered while the patient is still in hospital if the situation is considered high risk. Otherwise these patients may be sent home to recover then readmitted for angioplasty at a later date.
Patients with stable angina may be suitable for angioplasty depending on the site and number of lesions in the coronary arteries. Other considerations, such as the fitness of the patient for cardiac surgery may influence the decision to opt for angioplasty rather than coronary bypass surgery or simple tablet medication.
What are the possible complications?
Sometimes it is not possible to open the affected coronary artery especially if it is completely blocked rather than just narrowed. Depending on the site of the blockage the Cardiologist may then advise continuing medication or Coronary Artery Bypass Surgery.
The puncture site in the groin or wrist may bruise or become infected.
Rarely people may have an allergic reaction to the dye used.
Although a safe procedure, PCI is an operation on the heart and cannot be done without there being some risks. Serious complications are rare and are more likely to affect individuals in certain high risk groups. The Cardiologist will advise you of your individual risk and will only advise the procedure if the benefits outweigh that risk. Serious complications include:-
· A heart attack during the procedure (less than 1:100 cases).
· Emergency cardiac surgery (less than 1:200 cases).
· A stroke
· Death
In the longer term, stents deployed in arteries can sometimes gradually re-narrow. This can lead to a return of angina pains or even a heart attack. Thankfully, this process of “re-narrowing” within stents known as in-stent restenosis only affects a minority of patients. Newer stents which are coated with a drug to prevent this restenosis have been very effective. However, occasionally the PCI procedure may need to be repeated if restenosis occurs.
Driving after angioplasty
Patients may start driving a car again one week after angioplasty. If they have had a heart attack however, they are not permitted to drive for at least 4 weeks.
For PSV or HGV drivers, the Group 2 driving entitlement is withdrawn immediately that a diagnosis of angina is made pending further investigations. After angioplasty or bypass surgery, the licence may be reinstated after a period of time provided they pass a careful assessment by the Cardiologist. This often includes an exercise ECG. After a heart attack the Group 2 entitlement is withdrawn for at least 3 months but they must still pass this assessment before it can be reinstated.