(Balloon Angioplasty, Percutanous Transluminal Coronary Angioplasty [PTCA], Percutaneous Coronary Revascularization )

by Editorial Staff and Contributors

Definition

The insertion of a catheter carrying a balloon, through an artery in the groin or arm, into a blocked artery in the heart. The balloon is quickly inflated and deflated to open the artery to allow blood flow.

Parts of the Body Involved

• An artery in the groin or arm
• Arteries leading to the heart
• Coronary (heart) arteries

Reasons for Procedure

To open a blocked artery in the heart to allow more normal blood flow through that artery. In recent years, angioplasty has been used for many patients after a heart attack to open the blocked artery that leads to the heart attack, even if it occurred days or weeks before.

Doctors thought that opening a blocked artery would have long-term benefits and extend one's life. A new study examined the role and best timing for angioplasty. Two thousand one hundred sixty-six patients who suffered a heart attack 3-28 days before were randomly divided into two groups and followed for three years. One group was treated with angioplasty and stent placement and heart medicines, and the other group was only treated with heart medications. After three years, there were no significant differences between those groups in terms of heart attacks, heart failure, or death.

This study is likely to change the way patients are treated after a heart attack, but more research is needed to define more precisely who would benefit from this procedure the most.

Risk Factors for Complications During the Procedure

• Allergies to medications, shellfish, or x-ray dye
• Obesity
• Smoking
• Bleeding disorder
• Age: 60 or older
• Recent pneumonia
• Recent heart attack
• Diabetes
• Kidney disease
• Angina
• Hardening of blood vessels

What to Expect

Prior to Procedure

Your doctor will likely do the following:

• Blood tests, especially if you are taking certain medications (high blood pressure pills, blood thinners, heart medications)
• Electrocardiogram (ECG, EKG)—a test that records the heart's activity by measuring electrical currents through the heart muscle
• Chest x-ray

In the days leading up to your procedure:

• The night before, eat a light meal and do not eat or drink anything after midnight.
• You may be asked to shower the morning of your procedure, and you may be given special antibacterial soap to use.
• Arrange for a ride to and from the procedure.
• Arrange for help at home after returning from the hospital.

During Procedure

• IV fluids
• Fluoroscopy/x-rays
• Heart rhythm monitoring
• Sedation
• Anesthesia
• Possibly the blood thinner heparin to decrease the risk of blood clots
• Pulse oximetry to monitor blood oxygen levels
• Anesthesia
• Local anesthetic to the area of the groin or arm where the catheter will be inserted

Description of the Procedure

The area of the groin or arm where the catheter will be inserted is shaved, cleaned, and numbed with local anesthetic. The doctor inserts a needle into the artery, and a wire is passed through the needle. The wire is guided through the arterial system until it reaches the blocked artery in the heart. Next, a soft, flexible catheter tube is slipped over the wire and threaded up to the blockage.

This procedure is monitored using a continuous x-ray image called fluoroscopy. Dye can be injected through the catheter into the arteries of the heart to better visualize the arteries and the blockages. Once the blockage is reached, a small balloon at the tip of the catheter is rapidly inflated and deflated, stretching the artery open. The deflated balloon, catheter, and wire are then removed, and a bandage is placed over the groin or arm area. Depending on the size and location of the blockage, your doctor may insert a small mesh tube, called a stent (a metallic scaffold that is inserted into a vessel to prevent its narrowing), in the newly opened area to prevent the artery from narrowing in the future.

After Procedure

If the catheter was inserted through your groin, you will need to lie flat on your back, keeping your leg still for about six hours after the procedure. You may have a sandbag placed over the area in your groin where the catheter was inserted to put pressure on the artery and prevent bleeding. If the catheter was inserted in your arm, you will be required to keep your arm straight using an arm board.

How Long Will It Take?

Between 30 minutes and three hours

Will It Hurt?

The local anesthetic should adequately numb the area where the catheter is inserted, so the entry site shouldn't be painful. However, you may feel a burning sensation when the area is anesthetized, and you may feel pressure when the catheters are manipulated. Some people have a flushing feeling or nausea when the dye is injected. You may feel some chest pain during inflation of the balloon.

Possible Complications

• Bleeding at the point of the catheter insertion
• Perforation of the artery in the heart, requiring immediate emergency bypass surgery
• Spasm of the artery
• Heart arrhythmia (abnormal heart beats)
• Heart attack
• Stroke
• Allergic reaction to x-ray dye
• Blood clots may form and travel through your arteries, causing stroke, heart attack, kidney damage, breathing difficulties, damage to an arm or leg, or intestinal damage
• Infection
• Narrowing of an artery requiring additional procedure or surgery
• Average Hospital Stay 0- 2 days
• Postoperative Care

You may be sent home on blood thinning therapy, either aspirin or another medication, such as warfarin or agents that inhibit platelets clumping (eg, Plavix).

To minimize pain and soreness, you can place ice at the insertion area for 15-20 minutes each hour, for the first two days. After this time, switch to a heating pad or hot water bottle.
To lower your risk of recurrent blockages in your coronary arteries and further heart disease, make lifestyle changes, including eating a healthier diet, exercising regularly, and managing stress.

You may need to undergo periodic stress tests to monitor for any early-on recurrent blockages.

Outcome

Your artery should be considerably more open, allowing better blood flow to feed the heart muscle. This may mean that you'll no longer have the chest pain that you previously experienced, or it may mean that your tolerance for exercise will increase. Sometimes, however, the procedure isn't successful, or the artery narrows again, in which case you may require repeat angioplasty or coronary artery bypass grafting (CABG).
Since the early 1990s, techniques that do not use balloon for opening of the arteries have become more commonly used. Those involve revascularization procedures with the use of stent placement or mechanical removal of cholesterol plaques within a blood vessel, called an atherectomy.

In a recent review of 23 studies, involving 9,963 patients, CABG was compared to percutaneous coronary intervention (PCI), which consisted of catheter-based techniques using balloon angioplasty or coronary stenting. At the one-year and five-year follow-ups, the survival rate was similar for the two procedures. But, patients who received CABG experienced an increased rate of angina relief and a decreased rate of having another revascularization procedure compared to those who underwent PCI. The short-term risk of stroke, though, was higher after CABG than PCI. *

Call Your Doctor If Any of the Following Occurs

• Chest pain
• Your arm or leg becomes painful, blue, cold, numb, tingly, swollen, or increasingly bruised
• Cough, shortness of breath, chest pain, or severe nausea, or vomiting
• Redness, swelling, increasing pain, excessive bleeding, or discharge from the insertion site in the groin or arm
• Signs of infection, including fever and/or chills

RESOURCES:
American Heart Association
http://www.americanheart.org

National Heart, Lung, and Blood Institute
http://www.nhlbi.nih.gov/health/dci/inde...

CANADIAN RESOURCES:
Heart and Stroke Foundation of Canada
http://ww2.heartandstroke.ca/Page.asp?Pa...

University of Ottawa Heart Institute
http://www.ottawaheart.ca/UOHI/Welcome.d...

REFERENCES:

American Heart Association website. Available at: http://www.americanheart.org/presenter.j.... Accessed October 14, 2005.

Angioplasty. National Heart, Lung, and Blood Institute website. Available at: . Accessed October 14, 2005.

Baim D, Grossman W. Coronary Angioplasty, in Cardiac Catheterization, Angiography, and Intervention. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2000.

Harrison's Priniciples of Internal Medicine. 16th ed. McGraw-Hill Professional; 2004.

Heart Disease: A Textbook of Cardiovascular Medicine. 5th ed. Philadelphia, PA: WB Saunders; 1997.

Hochman J, Lamas GA, Buller CE, et al. Coronary intervention for persistent occlusion after myocardial infarction. N J Eng Med. 2006;355:2395-2407. Available at: http://content.nejm.org/cgi/content/abst.... Accessed November 14, 2006.

Smith SC, Dove JT, Jacobs AK, et al. ACC/AHA guidelines of percutaneous coronary interventions. J Am Coll Cardiol. 2001;37:2215.

Updated Outcome section on 11/7/2007 according to the following study, as cited by http://www.ebscohost.com/dynamed/what.ph... Bravata DM, Gienger AL, McDonald KM, et al. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med. 2007 Nov 20. [Epub ahead of print]

Last reviewed November 2007 by J. Peter Oettgen, MD

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