(PTCA, Percutaneous Coronary Intervention, PCI)
Percutaneous transluminal coronary angioplasty (PTCA) is performed to open blocked coronary arteries caused by coronary artery disease (CAD) and to restore arterial blood flow to the heart tissue without open-heart surgery. A special catheter (long hollow tube) is inserted into the coronary artery to be treated. This catheter has a tiny balloon at its tip. The balloon is inflated once the catheter has been placed into the narrowed area of the coronary artery. The inflation of the balloon compresses the fatty tissue in the artery and makes a larger opening inside the artery for improved blood flow.
The use of fluoroscopy (a special type of X-ray, similar to an X-ray “movie”) assists the doctor in the location of blockages in the coronary arteries as the contrast dye moves through the arteries. A small sample of heart tissue (called a biopsy) may be obtained during the procedure to be examined later under the microscope for abnormalities.
A technique called intravascular ultrasound (IVUS), a technique that uses a computer and a transducer that sends out ultrasonic sound waves to create images of the blood vessels, may be used during PTCA. The use of IVUS provides direct visualization and measurement of the inside of the blood vessels and may assist the doctor in selecting the appropriate size of balloons and/or stents, to ensure that a stent, if used, is properly opened, or to evaluate the use of other angioplasty instruments.
The doctor may determine that another type of procedure is necessary. This may include the use of atherectomy (removal of plaque) at the site of the narrowing of the artery. In atherectomy, there may be tiny blades on a balloon or a rotating tip at the end of the catheter. When the catheter reaches the narrowed spot in the artery, the plaque is broken up or cut away to open the artery. Atherectomy is used when the plaque is calcified, hardened, or if the vessel is completely closed. Another type of atherectomy procedure uses a laser, which opens the artery by "vaporizing" the plaque.
In the past few years, many refinements have been developed in the PTCA procedure. One common procedure used in PTCA is stent placement. A stent is a tiny, expandable metal coil that is inserted into the newly-opened area of the artery to help keep the artery from narrowing or closing again.
Once the stent has been placed, tissue will begin to form over it within a few days after the procedure. The stent will be completely covered by tissue within a month or so. It is necessary to take medications, such as aspirin, clopidogrel (Plavix), prasugrel (Effient), or ticagrelor (Brilinta), which decrease the “stickiness” of platelets (special blood cells that clump together to stop bleeding), in order to prevent blood clots from forming inside the stent. Your doctor will provide specific instructions regarding which medications need to be taken and for how long.
Newer stents (drug-eluting stents, or DES) are coated with medication to prevent the formation of scar tissue inside the stent. These drug-eluting stents release medication within the blood vessel itself. This medication inhibits the overgrowth of tissue that can occur within the stent. The effect of this medication is to deter the narrowing of the newly stented blood vessel.
If scar tissue does form inside the stent, radiation therapy (called brachytherapy) may be used to clear the scarred area and open up the vessel.
Other related procedures that may be used to assess the heart include resting or exercise electrocardiogram (ECG or EKG), Holter monitor, signal-averaged ECG, cardiac catheterization, chest X-ray, computed tomography (CT scan) of the chest, echocardiography, electrophysiological studies, magnetic resonance imaging (MRI) of the heart, myocardial perfusion scans, radionuclide angiography, and cardiac CT scan. Please see these procedures for additional information.
Coronary artery disease (CAD) is the narrowing of the coronary arteries (the blood vessels that supply oxygen and nutrients to the heart muscle), caused by a buildup of fatty material within the walls of the arteries. This process causes the inside of the arteries to become rough and narrowed, limiting the supply of oxygen-rich blood to the heart muscle.
To better understand how coronary artery disease affects the heart, a review of basic heart anatomy and function follows.
The heart is basically a pump. The heart is made up of specialized muscle tissue, called the myocardium. The heart's primary function is to pump blood throughout the body, so that the body's tissues can receive oxygen and nutrients.
Like any pump, the heart requires fuel in order to work. The myocardium requires oxygen and nutrients, just like any other tissue in the body. However, the blood that passes through the heart's chambers is only passing through on its trip to the rest of the body. This blood does not give oxygen and nutrients to the myocardium. The myocardium receives its oxygen and nutrients from the coronary arteries, which lie on the outside of the heart.
When the heart tissue does not receive an adequate blood supply, it cannot function as well as it should. If the myocardium's blood supply is decreased for a length of time, a condition called ischemia develops. Ischemia can decrease the heart's pumping ability, because the heart muscle becomes weakened due to a lack of nutrients and oxygen.
Unfortunately, you may not have any symptoms of early coronary artery disease, yet the disease may continue to progress until sufficient artery blockage occurs, leading to angina (chest pain or discomfort due to coronary artery disease). Symptoms of angina include chest or arm pain, chest pressure, fatigue, indigestion, palpitations, and shortness of breath.
If a coronary artery is completely closed by a blood clot, a myocardial infarction (heart attack) may occur. The blood clot may occur when a plaque (buildup of fatty tissue inside the artery walls) ruptures. If the blood flow cannot be restored quickly to the particular area of the heart muscle affected, the tissue dies.
PTCA is performed to restore coronary artery blood flow when the narrowed artery is in a location that can be reached in this manner. Not all coronary artery disease can be treated with PTCA. Your doctor will decide the best treatment of your CAD based on your individual circumstances.
There may be other reasons for your doctor to recommend a PTCA.
Possible risks associated with PTCA, atherectomy, and/or stent include, but are not limited to, the following:
You may want to ask your doctor about the amount of radiation used during the procedure and the risks related to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such as previous scans and other types of X-rays, so that you can inform your doctor. Risks associated with radiation exposure may be related to the cumulative number of X-ray examinations and/or treatments over a long period of time.
If you are pregnant or suspect that you may be pregnant, you should notify your doctor due to risk of injury to the fetus from a PTCA. Radiation exposure during pregnancy may lead to birth defects. If you are lactating, or breastfeeding, you should notify your doctor.
There is a risk for allergic reaction to the dye. Patients who are allergic to or sensitive to medications, contrast dye, or iodine should notify their doctor. Also, patients with kidney failure or other kidney problems should notify their doctor.
For some patients, having to lie still on the procedure table for the length of the procedure may cause some discomfort or pain.
There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.
A PTCA may be performed as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.
Generally, a PTCA follows this process:
After the procedure, you may be taken to the recovery room for observation or returned to your hospital room. You will remain flat in bed for several hours after the procedure. A nurse will monitor your vital signs, the insertion site, and circulation or sensation in the affected leg or arm.
You should immediately inform your nurse if you feel any chest pain or tightness, or any other pain, as well as any feelings of warmth, bleeding, or pain at the insertion site in your leg or arm.
Bedrest may vary from two to six hours depending on your specific condition. If your doctor placed a closure device, your bedrest may be of shorter duration.
In some cases, the sheath or introducer may be left in the insertion site. If so, the period of bedrest will be prolonged until the sheath is removed. After the sheath is removed, you may be given a light meal.
You may feel the urge to urinate frequently because of the effects of the contrast dye and increased fluids. You will need to use a bedpan or urinal while on bedrest so that your affected leg or arm will not be bent.
After the specified period of bed rest has been completed, you may get out of bed. The nurse will assist you the first time you get up, and will check your blood pressure while you are lying in bed, sitting, and standing. You should move slowly when getting up from the bed to avoid any dizziness from the long period of bedrest.
You may be given pain medication for pain or discomfort related to the insertion site or having to lie flat and still for a prolonged period.
You will be encouraged to drink water and other fluids to help flush the contrast dye from your body.
You may resume your usual diet after the procedure, unless your doctor decides otherwise.
You will most likely spend the night in the hospital after your procedure. Depending on your condition and the results of your procedure, your stay may be longer. You will receive detailed instructions for your discharge and recovery period.
Once at home, you should monitor the insertion site for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the insertion site. A small bruise is normal. If you notice a constant or large amount of blood at the site that cannot be contained with a small dressing, notify your doctor.
If your doctor used a closure device for your insertion site, you will be given specific information regarding the type of closure device that was used and how to take care of the insertion site. There will be a small knot, or lump, under the skin, where the insertion site was. This is normal. The knot should gradually disappear over a few weeks.
It will be important to keep the insertion site clean and dry. Your doctor will give you specific bathing instructions.
You may be advised not to participate in any strenuous activities. Your doctor will instruct you about when you can return to work and resume normal activities.
Notify your doctor to report any of the following:
Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.
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