Coronary angioplasty and stenting

What it is

A narrowed or blocked coronary artery is opened from inside. A fine wire is steered across the narrowing through a catheter from the wrist or groin, a balloon is inflated to crush the plaque against the wall, and a drug-coated metal mesh stent is expanded to hold the artery open. As primary PCI it is the emergency treatment for a heart attack; electively it relieves angina.

Why it is done

• ST-elevation heart attack (STEMI): open the artery within 120 minutes of diagnosis
• Non-ST-elevation heart attack and unstable angina, usually within days
• Stable angina not controlled by medication, or with a large area of ischaemia on testing

Before the procedure

• ECG, troponin, kidney function, clotting; a loading dose of aspirin and a second antiplatelet
• Nil by mouth if elective; in an emergency straight to the catheter lab
• Local anaesthetic to the wrist; mild sedation

Step by step

1. A sheath is placed in the radial (or femoral) artery and heparin given
2. Catheters are passed to the origin of each coronary artery and contrast injected to map the narrowings
3. A guidewire is steered across the lesion
4. A balloon is inflated for seconds to open the narrowing, with the ECG watched for ischaemia
5. A drug-eluting stent on a balloon is positioned and expanded to the artery's size; a final angiogram confirms flow
6. The sheath is removed and the wrist compressed with a band

Afterwards

• Bed rest for a few hours (longer for femoral access); home the next day for elective cases, 2-3 days after a heart attack
• Dual antiplatelet therapy for 6-12 months to stop clot forming on the stent, then aspirin for life
• Statin, beta blocker and ACE inhibitor as indicated; cardiac rehabilitation

Recovery

Back to light activity within days and work in a week or two for elective procedures; after a heart attack, structured rehabilitation over 6-12 weeks.