Medications and lifestyle changes are not always enough to prevent a heart attack. A person who comes to the hospital with severe angina or a heart attack probably has one or more coronary arteries that are com- pletely blocked. The ?rst priority is to restore blood ?ow immediately, and the next concern is to reduce the risk of another heart attack. Your risk is especially high if your heart’s pumping ability has been compro- mised by damage, if you have blockages in three or more arteries, or if one of the blockages is in the left main coronary artery, which supplies the powerful left ventricle. Angioplasty, or balloon angioplasty, is a pro- cedure that opens a blocked artery by compressing the plaque against the walls of the artery to clear a wider channel.
Angioplasty is also called percutaneous (through the skin) transluminal (in an artery) coronary angioplasty (PTCA). The procedure is done by inserting a catheter into an artery, usually in the groin, to pass it through the aorta to the heart. When the balloon reaches the site of the blockage, it is in?ated to compress the plaque.
By opening an artery, angioplasty effectively relieves the pain of angina and minimizes damage to the heart. It may be done as an emer- gency procedure when a person arrives at the hospital in the midst of a heart attack. Angioplasty may also be performed on a nonemergency basis, to relieve angina symptoms or to try to prevent a heart attack. In the United States, more than 1.2 million angioplasties were performed in a recent year in people with coronary artery disease.
In most cases (70 to 90 percent) of angioplasty proce- dure, the doctor will insert a stent into the artery (a device to support the walls from the inside). Some stents are cov- ered with medications that help reduce the risk of clot formation. The reason that stents are not placed in some people is the location and the type of lesion.
The main purpose of a stent is to reduce the possibil- ity of the artery narrowing again in the same place, a process called restenosis. Restenosis occurs in about 40 percent of people with angioplasty alone, and only about 20 percent of people with angioplasty and
stenting. For reasons that are unclear, people with diabetes are at increased risk for restenosis.
If your doctor recommends that you have an angio- plasty, you will probably have a chest X-ray, an electro- cardiogram (see page 122), and blood tests before the procedure. You and your doctor can thoroughly discuss why you are having the angioplasty, how it will be done, and what you can expect afterward. Be sure to talk about any medications you are taking; your doctor may ask you to stop taking them—particularly antiplatelet or antico- agulant drugs—before the procedure. You will also be asked not to eat or drink anything after midnight before the procedure. If you have diabetes, talk to your doctor in detail about your medications and your food intake, because either of these factors affects your blood sugar levels

How Angioplasty Is Done

An angioplasty is usually done in a catheterization laboratory, often called the cath lab. Electrodes will be placed on your chest and you will be connected to an electrocardiogram machine to monitor your heart during the procedure. You do not need a general anesthetic, but you will receive an intravenous sedative. The area of your leg (or sometimes the arm) where the catheter will be inserted will be anesthetized, then cleansed and shaved. After this area is numbed, you will not feel any pain during the procedure, but you will be awake.
The doctor will locate the appropriate artery and insert a catheter (a thin tube) through the skin. He or she will guide the catheter through the artery up the aorta and into your heart, watching its path on a monitor. When the catheter is at the opening of the coronary artery, a dye is injected so that the doctor can take an image of the arteries (an angiogram; ) and see on the monitor if there is a blockage of blood ?ow within the artery. After studying the size and extent of the blockage, he or she may insert a tiny balloon-tipped device, guide it to the site of the blockage, and then in?ate the balloon, which will expand against the walls of the artery. The in?ated balloon is kept in place for up to 2 minutes and then de?ated. The doc- tor can inflate it several times if necessary to shape the inside of the artery. When the results are satisfactory, the de?ated balloon and catheter are removed.
How Stents Are Placed

A stent is a piece of tubing made of springy wire mesh. It is placed over the balloon on the tip of the catheter and guided into position in the cleared artery. Then the balloon is in?ated and the stent expands, locks in place, and props the artery open, with the compressed plaque behind it. The balloon is de?ated and removed, and the stent remains permanently. Within a few weeks, new tissue forms over the surface of the stent so that the interior passageway is smooth. Stenting can be done alone, but is usually done in combination with angioplasty. The surgeon can work on several blocked arteries during one procedure.

After the Procedure

An angioplasty procedure is likely to last from 45 minutes to more than
2 hours. After the procedure is done and the catheter is removed, the doctors or nurses will stop the bleeding by applying pressure, either manually or with specially designed pressure devices, for 20 minutes or more over the place where the catheter was inserted, and then will bandage the area. You will feel sleepy until the sedative wears off. You will be asked to lie very still during the recovery period for up to 8 hours. A nurse will monitor your heart and blood pressure and will check the incision site fre- quently for signs of excessive bleeding or damage to the blood ?ow through the artery. You will probably spend from 1 to 2 days in the hospital.
You will have to arrange to have someone drive you home, and you should not drive for several days after- ward, while the incision is still healing. Your doctor will ask you not to bathe, or stand and walk for long periods of time, for at least 2 days after the procedure. Once you get home, call your doctor promptly if you see any bleeding or swelling at the site of the incision or if you have a fever, which is a possible sign of an infection. If you have a stent, you should probably avoid exercising vigorously for about 30 days. However, there are many cases on record of people returning to work or exercise

sooner than that; ask your doctor what is best for you.
Your doctor may prescribe medications such as nitroglycerin to relax the coronary arteries, calcium antagonists to guard against coronary artery spasm , or aspirin and other antiplatelet drugs to prevent blood clots in the area of the blockage. If you have a stent, you will have to take blood thinners (such as aspirin) inde?nitely. You will also take an antiplatelet such as clopidogrel  at least one month after a bare-metal stent is placed in your artery and two or more years after a drug-eluting stent is placed in your artery. Because of the presence of the metal stent, you should not have magnetic resonance imaging (MRI) for at least 4 weeks with- out checking with your doctor ?rst. But you can go through a metal detector at an airport without a problem.


Restenosis (renarrowing or constriction) can occur in the same area of the blood vessel where your angioplasty was done, often within about 6 months of the original procedure. Although placement of a stent greatly reduces the likelihood that this will happen, restenosis can occur in an artery with a stent (in-stent restenosis). The artery becomes blocked again because, in addition to the healthy new tissue that forms over the stent, scar tissue can develop under the surface that becomes so thick it obstructs the blood ?ow again. People with diabetes have a higher risk of restenosis, but it can occur in other patients as well, depending in part on the location of the blockage and the pattern of scar tissue growth.
If a restenosis occurs, the person is likely to experience the same types of symptoms (chest pain after exertion) that he or she felt before the ?rst angioplasty was done. (A patient with diabetes may have fewer or less typical symptoms.) Fortunately, restenosis very rarely causes a heart attack. Your doctor will be watching closely to detect restenosis and to check for blockages in other arteries by monitoring your symp- toms and having you take a follow-up exercise stress test. Be sure to report promptly any symptoms that you experience after your angio- plasty. If a restenosis does occur, another angioplasty or bypass surgery may be required to correct the blockage.
Of course, doctors are searching for ways to prevent restenosis. A major advance has been the development of drug-eluting stents—that is, devices that are coated with slow-release medications that penetrate the surrounding tissue to prevent the growth of scar tissue. Drug- eluting stents appear to substantially improve the long-term success of angioplasty procedures, though they also increase the short-term risk of clot formation. If you have a drug-eluting stent, you will need to take clopidogrel for at least two years and aspirin inde?nitely. Before sur- gery, ask your cardiologist if a bare-metal stent or drug-eluting stent is best for you.
Doctors at some medical centers are working with a procedure called brachytherapy, which uses radiation to stop tissue growth around a stent. A catheter with a radioactive tip is threaded into the blockage around a stent and a dose of radiation is administered. Although the radiation lasts only about 10 minutes, it inhibits long-term growth of tissue. Brachytherapy is not widely available, however, and needs study.
You can help protect yourself from restenosis by leading a heart- healthy lifestyle after angioplasty. Quit smoking, eat a low-fat diet, get regular exercise, take your medications, and follow up regularly with your physician to contribute to the success of your angioplasty. A car- diac rehabilitation program will offer advice and support to help you incorporate these vital changes into your life .