Coronary Angioplasty

So, you've been referred for a coronary angioplasty. That is a balloon that we use to dilate a narrowing, to widen a narrowing in one of your coronary arteries, and almost invariably these days we'll put a scaffold in as well called a stent to try and keep your artery open. The reason we're doing it will have been discussed with you in advance, and you should have been sent a patient information sheet so you can read up about the pros and cons of having this treatment compared to medical therapy or even bypass surgery. So how is it going to be done? Well, you've already had an angiogram and the angiogram would be done either from the leg or from the wrist to try and get the diagnostic pictures. Sometimes we do the diagnostic pictures and the treatment on the day and if that is your situation then you will either have a puncture from the leg artery, the femoral artery or through the wrist artery, the radial artery, because both those arteries lead up to the heart. If we haven't taken the pictures already, we certainly will be taking some pictures. And if there's a narrowing, we may decide to do a further assessment with what is called a pressure wire. It's the equivalent of actually doing an exercise test without you needing to do anything at all on the table to decide whether that narrowing is significant or not. That carries a very small risk. But then when we carry on and do a stenting procedure, then the way that stenting works is to produce a small tear in the artery. If the artery is narrowed, a bit like a circle, then the only way to open it is to open that circle up, producing a bit of a tear, and then we seal the tear with a stent. So we can't open the artery without producing a tear, but because we produce a tear, there is a small risk. I would say that the risk in most people having a coronary stent is about 1%. So 1 in 100 people may have localized bleeding or bruising from the puncture point. They may set off a heart attack because we tear the blood vessel and maybe sometimes a small clot goes down beyond the stent and causes a small heart attack. We can set off a stroke because we have to go past the brain blood vessels to get to the heart blood vessels. We thin the blood as well, so there's a small risk of internal bleeding. And of course, if any of those things are catastrophic, there's a small risk of death. Now, the only reason we're considering doing this treatment is either because you have symptoms of angina and we want to get rid of those, or even if the angina is not too bad, the narrowing is in a very important spot so that treating it and giving your heart more blood is seen as advantageous to you living longer. In the context, if you were admitted into hospital with already having had a heart attack, then re-plumbing really does save lives, and we may be doing it for that reason. So if we didn't do it, then remember, even if you have stable angina, there's a three in a hundred chance of some problem occurring with your heart this year. So the one in a hundred chance, I'm quoting, of a complication occurring has to be balanced with the fact that you're not in the clear if we just leave it all on tablet therapy. Tablets are good, and if you want to continue on only tablets, you have the opportunity to say no to the stenting procedure discuss it with your doctor further. So there are alternatives available, which of course you should consider. When we've done the procedure, you will be monitored for a period of time afterwards, usually about four hours. So you'll be attached to an ECG machine, there'll be beeps going on, the nurses will take your observations regularly, in particular looking at the ECG to make sure there's been no changes in your heart traces, and to look at the site that we've punctured to make sure it's clean and dry and not bruising. Often we'll send you home the same day. There must be someone at home to look after you. Not that you'll need a lot of looking after, but if there is a problem with that puncture site or you start getting chest pains, you should not be alone. Someone needs to make a phone call and get some attention for you. When will you recover? Well, if we do a stenting procedure, we really do advise you not to drive for at least a week afterwards. Not really because I'm worried about the heart, but mainly because I'm worried about the puncture point. If you're staring at your leg because it hurts and you're driving along, you're not looking at the road. So I'd advise you not to drive for a week. Can you go back to work? Well, a week later, yes, you can go back to work. Can you fly? Again, a week later, you should be able to fly. Most airlines will allow you to fly, unless you've had a heart attack recently, of course, in which case it's probably going to be about four weeks. And after that time, you should be able to go back to all the activity, hopefully feeling better, you will need to be taking some blood thinners. So you'll take aspirin and another drug, which is aspirin's big brother. There are a number of them available. You may be on one of those. You'll certainly be on at least one of them, because if you don't have it and we have a stent in, or if you lose your tablet, if you stop the aspirin and this new drug, you will be in trouble with your stent. I advise you very strongly to make sure you take those tablets for one year. Normally we'll recommend a year of these dual anti-platelet therapy, that's what it's called, DATP, dual anti-platelet therapy, aspirin plus aspirin's big brother for one year to make sure the stent beds in correctly. Don't stop those tablets. What can you expect thereafter? You'll be seen in cardiac rehabilitation, so the nurses there are fantastic at telling you about your diet, what exercise you can do, can you go back to all your activity, including, people are nervous about asking what happens in the bedroom and normally there should be absolutely no problem, you can carry on as you were before. It's not going to cure you of your long term problems, but there's no risk to your heart by undertaking anything you want to do in the bedroom either. So you can drive, you can go back to work, you can undertake sexual activities, all of that is perfectly possible within a week. What about the wound? It's a small puncture, so keep that dry for a week. You can have a shower, put a bandaid on it, but you need to keep that wound dry. No swimming, no baths for one week to make sure that wound heals up completely. If you do have any problems like chest pain or bruising or a lump appearing at the site we did the puncture, you need to get back in touch with the hospital so we can have a look at it to decide what to do next about it. So long term, normally there is no problem with the stent. About 5%, so 1 in 20 people, may have a re-narrowing that occurs in the stent, which often causes no symptoms, but can cause a recurrence of the angina. And if it does, the doctor can assess it again, we'll probably have to repeat the angiogram and decide whether further stenting is possible, it often is, whether tablets alone are okay on this occasion, they may be, or whether the disease has progressed and you need a bypass operation. It would be wrong of me not to mention a very small risk during the procedure that the artery tears so badly, we need to call our cardiac surgeon. You often will be rescued by further stenting, but if that's not the case, there's a very small possibility, rare these days, that we'll have to call for an emergency bypass operation, in which case the team is available to go and get you sorted out. That can be a life-saving maneuver, it's always very traumatic. On your consent form, you will have consented to have an emergency bypass operation, but I can assure you that's a fairly late occurrence and it's a rare occurrence and I would not worry too much about that possibility.