Angioplasty and Stenting

An angioplasty is performed to widen blood vessels where blood flow has been restricted due to plaque buildup. As you age, it is not uncommon for plaque (a gummy substance made of cholesterol, calcium, and fibrous tissue) to build up on the inside of artery walls. As more and more plaque accumulates, the arteries begin to narrow and stiffen causing atherosclerosis, or hardening of the arteries. When enough plaque builds up to interfere with blood flow, an angioplasty may be required to reduce any damage the reduced blood flow is causing.

Angioplasty widens the walls of blood vessels by the inflation of a small balloon inside the narrowed vessel. This pushes the excess plaque against the walls to create a more open blood vessel allowing for increased blood flow. During the procedure, a hollow needle will be inserted into your artery and the small balloon attached to a catheter will be threaded through the needle to reach the blockage within the blood vessel. In some cases, a permanent stent (a tube made of metal mesh) is placed into the narrowed area of the artery to keep it open and allow for unobstructed blood flow.

Commonly, your doctor will recommend angioplasty to treat peripheral arterial disease (PAD), which is the hardening of the arteries caused by diabetes, smoking, high blood pressure, and elevated cholesterol. Often, angioplasty and stenting is performed as an alternative to bypass surgery, a more invasive surgery used to treat PAD. However, if your PAD is widespread, your doctor may determine that bypass surgery is the best course of action.

Occasionally, angioplasty is used to treat restricted blood flow in the veins, which are blood vessels that carry oxygen-depleted blood to the heart.

Preparing for Angioplasty and Stenting

If your doctor suspects that treatment may be required for your PAD or another condition, he or she will seek a diagnosis by surveying your general health, inquiring about your medical history and possible risk factors, and asking you to describe your symptoms and how often they occur. This discussion is typically followed by a physical exam. After your patient history and exam are performed, tests are required to determine the extent of plaque buildup in your blood vessels. One or more tests may be performed to help your doctor decide the best treatment for your condition.

These tests may include:

  • Pulse volume recordings (PVRs)
  • Duplex ultrasound
  • Magnetic resonance angiography (MRA)
  • Computed tomography (CT) scan
If the tests that your doctor ordered determine that the plaque buildup is moderate to severe, a follow-up test called an angiography (angiogram) may be required. This is a minimally invasive procedure that provides a more detailed view of the blood vessels and can determine the specific location of blockages. When performing an angiogram, a special dye [properly referred to as contrast] is injected into the blood vessels through a catheter, making arteries visible on an X-ray. It is common for angioplasty and stenting to be performed during an angiogram since the narrowed area has already been reached via a catheter.

Patients who are good candidates for angioplasty and stenting typically have moderate to severe narrowing of the arteries and symptoms of PAD, such as pain or sores in one or more of your limbs.

If you have one or more of the following, you may not be a good candidate for angioplasty and stenting:

  • Extremely hard plaque buildup
  • Blockages that contain blood clots or excessive calcium
  • Extensive or very long blockages
  • Frequent blood vessel spasms
  • Complete blockages that cannot be breached
If angioplasty is right for you, your doctor may also test your kidney function and how well your blood clots to avoid any complications. Additionally, certain medications may have to be stopped in preparation for the procedure to reduce the risk of bleeding. Allergies to contrast dye or iodine should also be discussed with your doctor. Leading up to the angioplasty procedure, you will most likely be asked to refrain from eating and drinking and may be given an IV to deliver fluids.

The Procedure

Once your IV is connected, your doctor will then determine the point of insertion for the catheter. This is usually in your groin, but can also be in your arm. At the insertion site, your skin will be cleaned, any hair will be shaved, and a local anesthetic will be administered. Your doctor will then insert a hollow needle into your artery and a guide catheter and wire will be threaded through the needle to reach the correct position within the blood vessel. Typically, patients are awake during an angioplasty and mild sedatives and local anesthetics are used.

As the guide catheter and wire is positioned, X-rays of the area will be projected onto a screen so that the procedure is visible to your doctor. Positioning the guide catheter will not cause any pain or discomfort since your arteries have no nerve endings in them. Your surgeon will use a special balloon catheter that includes a deflated balloon on its tip. He or she will thread the balloon catheter and position it at the narrowed section of the blood vessel.

Your surgeon will then partially inflate the balloon by filling it with fluid to look for a pinch in the balloon caused by the plaque buildup in your artery. He or she will then slowly increase the balloon’s inflation until any pinch is flattened out. During this part of the procedure, some pain may occur because blood flow will stop for a short time, and the artery may stretch. This pain should go away once the balloon is deflated. However, it is important to let your surgeon know if you experience any discomfort during the procedure.

To prevent your artery from becoming narrowed (restenosis) or blocked (reocclusion) again, your surgeon may use a stent (a tube made of metal mesh) to keep your artery open. After the angioplasty is done, your surgeon will remove the balloon catheter and replace it with a catheter that carries a closed stent. Your surgeon will then guide the stent to the spot where the angioplasty was performed and deploy it in that location. Eventually, the walls of your artery will grow over the stent to help keep it in place.

Sometimes scar tissue may develop in the area where an angioplasty and stenting procedure was previously performed. If the scar tissue is heavy, restenosis (re-narrowing of the artery) can occur. To help avoid restenosis, scientists have developed a new kind of stent that is coated with drugs that help prevent scar tissue from forming. Early data on the efficacy of these news stents is promising. In the U.S., these stents are currently being used in coronary arteries. Testing is still being done on the use of these drug-coated stents in other arteries.

When your surgeon is satisfied with the angioplasty and stenting results, all catheters will be removed, and pressure will be applied to the point of insertion for 15 to 30 minutes. As an alternative to applying pressure, your surgeon may use stitches or plugs to seal the insertion site. If your surgeon has administered blood-thinning medication, he or she may leave a short tube or sheath in your artery until the medication has worn off enough to allow the insertion site to heal on its own once the sheath is removed.

After the Procedure

On the whole, an angioplasty and stenting procedure will take anywhere from 45 minutes to 3 hours or more, followed by up to six hours of monitoring in the hospital. Following the procedure, your vital signs will be monitored, and the insertion site should stay immobile for several hours to reduce bleeding. Once you are cleared to leave the hospital, you should arrange a ride home, as driving is prohibited after the procedure.

Any unusual symptoms should be immediately reported to your surgeon. Unusual symptoms may include:

  • Lingering or increasing pain in a limb
  • Fever
  • Shortness of breath
  • A limb that turns blue or feels cold
  • Bleeding, swelling, pain, or numbness at the insertion site
While you recover from the procedure at home, avoid lifting anything over ten pounds and drink extra fluids. Your surgeon will give you an additional list of instructions to follow regarding everyday activities, such as bathing, and may also provide you with an easy exercise routine to follow.

To help prevent blood clots from forming post-procedure, your doctor may also suggest that you take aspirin or other blood-thinning medications.

A follow-up appointment will be scheduled at which time your doctor will monitor your blood flow and check your medication dosages.

Risks & Complications

Typically, patients with diabetes, kidney disease, or blood clotting disorders have a greater risk of complications from an angioplasty and stenting procedFor patients with diabetes or kidney disease, the greatest risk is complications from the contrast dye. If you are at risk, your doctor may choose to pre-treat with fluids or medications to help reduce your chance of having complications. For patients with blood-clotting disorders, the greatest risks are excessive bleeding and an increased chance of restenosis or reocclusion.

It is rare to experience serious complications after an angioplasty and stenting procedure. However, there is a chance that they may occur.

Serious, but rare complications may include:

  • Reaction to contrast dye
  • A blood clot at the treatment site
  • A damaged or weakened blood vessel
  • Hematoma (a large collection of blood in one area)
  • Kidney problems
  • Damage to the artery lining
  • Embolization (blockages that occur when plaque separates from artery walls and obstructs blood flow downstream from the treatment site)

Other complications can also occur that are more easily treated, including:

  • Bleeding or bruising at the insertion site
  • A hole in the artery at the insertion site that doesn’t completely heal
  • An abnormal connection between an artery and a vein (rare)
Shortly after the procedure, your risk for blood clots is increased, so blood thinners may be prescribed to reduce this risk. Long-term risks include restenosis and reocclusion. If either of these conditions occurs, a repeat angioplasty or bypass surgery may be required.

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