Overview of Percutaneous Transluminal Coronary Angioplasty
Percutaneous transluminal coronary angioplasty (PTCA), also known as percutaneous coronary intervention (PCI), is a procedure that uses a minimal amount of invasion to open up blocked or narrowed arteries in the heart. This procedure allows blood to flow freely to the heart muscle. Sometimes, fatty deposits build up within the arteries, blocking blood flow to the heart. This build-up of fatty plaque is a condition called atherosclerosis.
When atherosclerosis affects the heart’s arteries, the condition is then known as coronary artery disease. People with this condition often feel chest pain when they exert themselves or struggle with breathlessness during physical activity. In severe cases, a part of the plaque can break off and form a clot. This blockage in a heart’s artery can cause a heart attack, or acute myocardial infarction. Symptoms during a heart attack often include intense chest pain, excessive sweating, and nausea. During such instances, an urgent PTCA procedure is commonly needed to reduce damage to the heart.
The PTCA technique was first developed in 1977 by Andreas Gruentzig, and it quickly spread worldwide as a preferred treatment for coronary artery disease. It has since become a very important procedure and now serves as the foundation for many other heart artery treatments. In fact, the PTCA was one of the most common procedures performed in the United States, accounting for 3.6% of all operating room procedures in 2011.
Anatomy and Physiology of Percutaneous Transluminal Coronary Angioplasty
The heart is supplied with blood through two main arteries known as the right and left coronary arteries. The left coronary artery, or LCA, divides into two smaller branches: the left anterior descending, or LAD, and the left circumflex artery, or LCX. These arteries are responsible for supplying blood to the left side of your heart.
In a similar way, the right coronary artery, or RCA, also splits into the right posterior descending, or PDA, and a posterolateral branch, known as PL. The RCA provides blood to the right side of your heart. Just like any other part of the body, your heart needs a constant supply of fresh blood to function properly. These coronary arteries are the only way of delivering this vital blood to your heart muscle.
Unfortunately, sometimes a condition called coronary artery disease can occur. This happens when plaque, which is a sticky substance made up of fat and other materials, builds up inside the coronary arteries. This plaque can clog the arteries, reducing the amount of blood that reaches the heart muscle. This can also lead to the arteries becoming narrower and sometimes getting completely blocked. If this happens, it can have serious health effects, as your heart will not get the amount of blood it needs to function properly.
Why do People Need Percutaneous Transluminal Coronary Angioplasty
A procedure called PTCA, or Percutaneous Transluminal Coronary Angioplasty, can be useful for certain patients. If a person has stable angina, or recurring chest pain or discomfort, which isn’t getting better with maximum medical treatment, PTCA can provide relief. Furthermore, if a patient is experiencing a STEMI, or ST-elevation Myocardial Infarction which is a type of severe heart attack, emergency PTCA is warranted. This procedure is done as soon as possible to prevent further damage to the heart muscle. On the other hand, if a person is having a NSTEMI, or Non-ST-elevation Myocardial Infarction, a less severe heart attack, or unstable angina (acute chest pain that suggests the heart isn’t getting enough blood), the PTCA procedure typically occurs within 24 to 48 hours.
When a Person Should Avoid Percutaneous Transluminal Coronary Angioplasty
There are only a few situations in which PTCA (a procedure to open up blocked arteries) might not be recommended. One such situation is if a patient has a condition called left main CAD (left main coronary artery disease). This condition involves the main artery that supplies blood to the heart, and there is a risk of severe complications like blockage or involuntary contraction during the procedure. Additionally, PTCA is not recommended if the narrowing of the heart’s arteries, called stenosis, is less pronounced (less than 70% narrowed). In these cases, the condition is not severe enough to warrant this procedure.
Equipment used for Percutaneous Transluminal Coronary Angioplasty
In the beginning, a procedure called PCI, which is used to unclog blood vessels, was done using balloon catheters alone. Balloon catheters are flexible tubes that can be inflated like a balloon to reshape and open up clogged arteries. However, the result was not always super successful, and sometimes the vessels would close up again.
That’s why they introduced different devices, like atherectomy devices and coronary stents. Atherectomy devices are special tools that cut or shave off the plaque (fatty deposits) clogging the artery. But when these were used on their own, the results were still not great.
The most popular devices now used in this procedure are coronary stents. They act like tiny scaffolds to prop open the arteries, and have improved the success rate of the procedure. There are different kinds, including traditional bare-metal stents and drug-eluting stents. Drug-eluting stents are special because they have a coating that helps to reduce inflammation and stop the cells that line the vessels from growing too much. Some of the most recent drug-eluting stents being used in the USA have drugs called sirolimus, everolimus, and zotarolimus on them. These newer stents have helped to reduce the chance of the stent causing a blood clot, which could be dangerous.
It’s really important for people who have had this procedure done to continue their medication to prevent blood clots, especially in the first 12 months after the procedure. This gives enough time for new healthy cells to form over the stent and help prevent a clot from forming.
Who is needed to perform Percutaneous Transluminal Coronary Angioplasty?
A procedure called PTCA is carried out by a special team. This team includes an interventional cardiologist, who is a heart doctor with expertise in treating blocked arteries, a nurse, and a radiology technologist, who is a specialist in using medical imaging machines. All members of the team have had a lot of special training to ensure they can perform the procedure properly and safely.
Preparing for Percutaneous Transluminal Coronary Angioplasty
A team of healthcare professionals will assess the patient and conduct some tests before deciding if they are a good candidate for the procedure. It’s very important to inform the team if the patient has any history of allergy to seafood or certain medications, as these could cause issues during the procedure. The patient will also need to undergo some blood tests to check their clotting time (PT and PTT), levels of important minerals in their body (serum electrolytes), kidney functionality (BUN and creatinine).
Proper hydration of the patient is crucial before the procedure. The patient’s medications will be reviewed, and blood-thinning drugs should be stopped, if possible, to reduce the risk of bleeding. Other common drugs, like those for pain or high blood pressure (NSAIDs or ACEIs), may also need to be paused to prevent possible kidney complications. If a patient has diabetes and is taking metformin, this drug will also be paused before the procedure to protect the kidneys and prevent a condition called lactic acidosis which is a buildup of lactic acid in the body that can be dangerous.
Patients will have to avoid eating or drinking anything 6 to 8 hours before the procedure. If they will access the patient’s heart through the radial artery (an artery in your arm), some special medications may be given to help keep the artery open and relaxed and to prevent blood clots. This might include calcium channel blockers, nitroglycerin, and heparin.
It’s important for the healthcare provider to fully explain the procedure and any potential risks or complications to the patient before getting their written consent to proceed.
How is Percutaneous Transluminal Coronary Angioplasty performed
The procedure you are undergoing is usually done using local anesthesia to numb a particular area of the body, so you won’t feel any pain. Moreover, you will be also given a sedative to help you feel calm and relaxed. The most common method we use to perform this procedure involves accessing a blood vessel in your thigh, called the femoral artery.
Initially, you will be given a small injection that numbs your skin and the tissues just beneath it, above your femoral artery. After this, a needle is inserted into this artery. When the needle is correctly positioned inside the femoral artery, a thin, flexible wire, or guidewire, is passed through the needle, into the blood vessel. Once done, the needle is removed, but the guidewire stays in place inside the blood vessel.
We then slide a thin tube (a “sheath”) and a device called an introducer over the guide wire and into your femoral artery. Once this is achieved, both the guidewire and introducer are taken out, leaving the sheath inside your artery. This gives us easy access to the artery for the next phase of the procedure.
Next, we move a “diagnostic catheter,” a long narrow tube, through the sheath. This catheter also has a long guide wire inside it. The catheter then is advanced using the guidewire, moving backwardly through several vessels, until it reaches your ascending aorta. The ascending aorta is the part of the main artery in your body that carries blood upwards from the heart. After reaching the ascending aorta, the guidewire is removed, leaving the tip of the diagnostic catheter in place. We then attach this catheter to a device called a manifold, which will allow us to inject a special dye (contrast), check pressure inside the arteries, and give any needed medications.
Now, we are ready to carefully move the diagnostic catheter into an area called the ostium. This is the opening of either the left main coronary artery or the right coronary artery, the main vessels that supply blood to your heart. When we’ve positioned the catheter correctly, we inject the contrast dye. This dye helps us to see these arteries during imaging tests. If we find a severely blocked artery, we can perform a procedure called Percutaneous Transluminal Coronary Angioplasty, or PTCA, to unblock it.
For this procedure, we replace the diagnostic catheter with a special guide catheter that has a larger opening, which makes it easier to move wires and balloons during the angioplasty procedure. A PTCA guidewire is then threaded through the guide catheter and across the blockage. We don’t remove this guidewire until the very end of the procedure.
Next, we take a wire with a tiny balloon attached (a “balloon wire”) and move it over the PTCA guidewire until the balloon is positioned directly over the blockage. Once in position, the balloon is inflated and deflated several times to push the blockage aside and unblock the artery.
In most cases, we also need to place a stent, a kind of tiny wire mesh tube, into the artery. The stent is crimped onto the ballon wire and placed at the site of the blockage. We then inflate the balloon to open the stent. Once the stent is opened fully, the balloon is deflated, and the stent stays in place permanently to help keep your artery open long-term.
We use the contrast dye and take multiple images to check the stent position and to confirm successful artery opening. After completing these steps, we remove the balloon wire, and finally, the PTCA guidewire.
During all this procedure, we are giving you medications to stop blood clots from forming. Depending on how difficult the procedure is, it can take anywhere from 30 minutes to 3 hours to complete.
Possible Complications of Percutaneous Transluminal Coronary Angioplasty
Percutaneous trans-luminal coronary angioplasty (PTCA), a procedure to open up blocked heart arteries, is commonly used and generally safe but does have some risks. It’s rare to have serious complications during the procedure, with only 1.2% of patients experiencing life-threatening issues.
People who are over 65 years old, or who have kidney disease, diabetes, or severe heart disease, and women are at a higher risk of dealing with complications. These complications can take several forms. For example, there might be swelling (hematoma) or a false aneurysm (a blood-filled swelling) at the site where the catheter (tube) was inserted into the femoral artery (large artery in your groin). There might also be an infection in the skin over this artery. In more serious cases, the procedure may lead to an embolism (a blood clot blocking blood flow), stroke, or kidney injury due to the contrast dye used for improving the viewing of the arteries. You could also have a bad reaction to the dye, or your artery may rupture or be torn (coronary artery dissection). Other complications can include bleeding, spasms in blood vessels, formation of dangerous blood clots, and acute myocardial infarction (often called a heart attack). Moreover, in the long-term, there is a risk that the artery that has been treated gets re-narrowed.
What Else Should I Know About Percutaneous Transluminal Coronary Angioplasty?
PTCA, or balloon angioplasty, is a procedure done to open up blood vessels in the heart that have been narrowed. This is done under a local anesthetic, which means the patient is awake but the area where the procedure is being done is numbed. PTCA is a less significant operation than coronary artery bypass surgery, often referred to as CABG, where blood flow around a blocked vessel is improved using a graft.
PTCA tends to be associated with less risk, shorter recovery periods, and is less costly than CABG. It also successfully improves blood flow in the heart’s blood vessels for about 90% of patients, reducing chest pain (angina) and enhancing the ability to do physical activity. In most cases, the procedure effectively removes the blocked part of the artery. However, it’s worth noting that different research studies have found varying conclusions about whether PTCA or CABG is more cost-effective for patients with heart muscle pain (myocardial ischemia) who don’t respond to medications.
