PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

Introduction

Coronary artery disease is the narrowing or obstruction of the vessels that supply blood and oxygen to the heart muscle. This narrowing is caused by fatty deposits (plaque) on the walls of the arteries.

These fatty deposits gradually build up and can cause a marked reduction of blood and oxygen to the heart. If the blood flow is significantly reduced, some form of medical treatment becomes necessary. The picture below shows a diseased LAD artery.

One of the most common non-surgical treatment for opening obstructed coronary arteries is Percutanueous Transluminal Coronary Angioplasty (PTCA). The name itself says a lot about the procedure:

Percutaneous : means access to the blood vessel is made through the skin

Transluminal : means the procedure is performed within the blood vessel

Coronary : specifies that the coronary artery is being treated

Angioplasty : means "to reshape" the blood vessel (with balloon inflation)

Also referred to as "balloon treatment" because special balloons are used to open up obstructed arteries. This procedure sometimes also involves the use of devices known as "stents" to help keep the arteries open.

The illustration below shows how a balloon catheter works to open an occluded artery.

Below is an illustration of a special catheter being used to install a stent device.

Below is a picture of the diseased vessel as illustrated above after it has undergone a successful PTCA procedure in which a stent was installed.

Following is a description of the PTCA procedure. It is important to realize that everyone's situation may be different, and each persons experience may vary slightly from the following outline of the procedure.

Step by step PTCA Procedure

Pre-Admission and Evaluation

You will not be permitted any food or beverages for four hours prior to the procedure to prevent nausea during the procedure. If you are a diabetic, you will be given special instructions. Your groin area will be washed and shaved in preparation for the PTCA.

Angioplasty Procedure

The length of the procedure depends on the complexity of each individual's situation, but in general, the duration is 1-3 hours.

An intravenous line will be started in your arm. You will receive various medications in the angioplasty laboratory though this line. To help you relax, you will be given medication prior to leaving for the lab. You will remain awake, but slightly drowsy.

You will be placed on an x-ray table upon your arrival in the lab. It is the same type of room in which you had your cardiac catheterization. All personnel in the lab will be wearing surgical attire. You will be covered by sterile sheets, and so will some of the equipment. Your groin (arm) will be cleansed with an antiseptic (might be cold) and then numbed with an anaesthetic. You will feel the sting of the needle, but then your groin (arm) will feel quite numb. Heart monitoring equipment will be placed on your arms and legs, and you may be given oxygen to breathe. You will be given certain medications through the intravenous line, and periodically medication will be given to relax you and decrease any restlessness. Remember, you must still be able to talk and follow directions.

The angioplasty catheter (balloon-tipped) is inserted at the numb area, and advanced to your heart, using x-ray guidance. When the balloon is inflated at the point of the blockage, you may feel chest pressure, or discomfort, and this is normal. It will subside when the balloon is deflated. You may also feel your heart thump or skip, feel flushed, or have a headache. All these sensations are normal. Always, however, let your doctor know exactly how you feel during the entire procedure. You will be asked at times to hold your breath for a few seconds. You may also be asked to cough. Try your best to cough forcefully, as you are instructed.

At the end of the procedure, a closure device may be used (angioseal or perclose). This will enable you to get up after about an hour.

After the procedure, you will be moved to a recovery area for a short time, and then taken to your room where your heart can be monitored. Nurses will closely monitor your vital signs and general well being. They will also frequently check the groin area and dressing. A small, flexible catheter is routinely left in the groin for 4-24 hours after the procedure. This allows quick access for a catheter should the need arise. Because of the catheter, you will be required to remain in bed and keep your leg immobilized.

You will be able to eat as soon as you wish after the procedure.

Recuperation

The catheter will be removed and firm pressure may be applied for about 20 minutes. Then a pressure bandage is applied and a small sandbag placed over it. This is to ensure that the artery does not bleed. Pain medication is available to you every few hours after the procedure. Please let your nurse know of any pain or discomfort you may feel at any time. The rest of the day is basically for rest, recuperation, and a gradual return to your activities.

Discharge

Your doctor will see you the morning of discharge. Your doctor's nurse will go over medications, activities, and follow-up care. You will receive prescriptions for medicines you will need.

You will usually undergo a low-level stress test very shortly after your discharge. You will be informed by the doctor or nurse when this will be. This stress test will help determine the extent of the success of your PTCA (by showing blood flow to your heart muscle). It also serves as a basis of guidance for your future exercise program.

POSSIBLE COMPLICATIONS AND RISK

No invasive procedure occurs without a certain amount of potential risk and complications. You are followed closely by your doctor and nurses, precisely for the reason that if any of these complications arise, corrective action can be taken immediately. The incidence of complications is low, but nonetheless, you need to be aware what they can be:

1. Severe bruising/bleeding into the groin area of the procedure leg. This may come to the surface over the next few weeks. If you are concerned, speak to your Cardiologist.
   
   
2. Changes in your heart rhythm.
   
   
3. Allergic reaction to the dye or to other medications used.
   
   
4. A tear in the lining of the artery which is being dilated.
   
   
5. Possibility of a heart attack or stroke during or following inflation of the balloon. (you are given strong blood thinners to minimize this risk.)
   
   
6. Possibility of a blood clot in the artery in which the catheter is inserted. (If this occurs, surgical removal may be required.)

Follow-up Care

Periodic follow-up with your personal physician is quite important. It is important for you to realize that by angioplasty (PTCA), your immediate problem has been taken care of, but it does not cure coronary artery disease. In some patients, re-narrowing of the artery may occur. If this happens, your original symptoms will return, or your stress test will be abnormal.

If you have chest discomfort, stop your activity, sit or lie down, and take nitroglycerine, as instructed. If the chest discomfort does not go away after 3 nitroglycerin tablets in a 20 minute period, DO NOT DELAY SEEKING MEDICAL ATTENTION. Either call your doctor, or go to an emergency room.

Cardiac Catherization, Percutanous Transluminal Coronary Angioplasty (PTCA) and stenting (PTCS)

These procedures involved taking the patient to a cardiac catherization laboratory. The laboratory area is shield from leakage of radiation. The patient is usually awake or under a mild sedation. Local anaesthetic will be applied to the groins or elbow. The catheters will be inserted through sheaths into the arteries and veins of the body and then pass up to the heart. Pressures within the different area of the heart is measured

and gradients across the valves calculated. Dye will be injected into the coronary arteries (LAD- left anterior descending artery, LCX-left circumflex artery and the RCA-right coronary artery) and the left ventricle to look for degrees of narrowing, site of the lesion and the ejection fraction (EF) of the left ventricle. Sometimes, the right side of the heart is also entered to check the pressure and the oxygen content of the blood. This would be of great help in diagnosis and grading of the severity of congenital heart disease (e.g. Atrial Septal Defect ASD, Ventricular Septal Defect VSD, etc.)