Central Cardiology Medical Clinic

Invasive Cardiology Procedures

Brijesh Bhambi, MD, FACC

EDUCATIONAL MATERIAL

CAUTION: The information presented here is for educational purposes only and is not a substitute for advice or individual medical care which should be provided by your personal physician. If you have questions regarding your health or symptoms described here, please contact your doctor for appropriate care.

Adequate functioning of various organs in our body are dependent upon delivery of nutrients and oxygen. Both the nutrients and oxygen are delivered via blood. The channels that carry these nutrients to different organs are called arteries. After transfer of the nutrients to different organs, blood is drained back to the heart through veins. An obstruction in either the arteries or the veins can compromise the function of the affected organ. Such a compromise in the function is more commonly seen with an obstruction on the arterial side. The reduced blood flow because of a partially narrowed artery can result in a number of malfunctions including discomfort and pain, depending upon the territory jeopardized. Also, depending upon the severity and the rapidity of the blockage development, extremely serious and potentially life-threatening emergencies like heart attack and stroke can develop. Fortunately, continuing advances in cardiovascular medicine have provided an in-depth insight into the mechanisms involved. Now we are in a position to identify people who are at a higher risk of developing such a complication by a variety of screening tools and, thus, preempt these complications, allowing in several instances a healthier and longer life. A number of factors increase the chances of plaque development in the arteries. These include diabetes, hypertension, elevated cholesterol (low HDL, high LDL, high LPa), family history of cardiovascular disease, sedentary lifestyle, exogenous obesity, presence of peripheral vascular disease, kidney malfunction, smoking, age, male gender, menopause, and sedentary lifestyle. From a preventative side, all these risk factors need to be looked into and, wherever possible, favorably reversed. However, in the presence of critical obstruction in the arteries that is causing significant discomfort and/or predisposing to potentially serious sequelae with loss of function and/or life more, immediate remedial/corrective measures need to be undertaken. In people suspected to be having significant obstructive problems in the coronary arteries, the problem can be precisely delineated with a relatively simple test called cardiac catheterization/coronary angiography.

Facts to know about Coronary Angiography

It requires hospitalization for 8 to 24 hours.
The procedure itself takes between 10 to 20 minutes.
Following angiography it is necessary to stay in bed for 6 to 7 hours to allow for adequate healing of the puncture site.
Cardiac catheterization is 99.7% safe. A procedure with 0.3 (3 in a 1000) risk of serious complications that include the risk of heart attack, stroke, and loss of life. These complications usually occur more commonly in people who have diabetes, kidney failure, congestive heart failure, advanced vascular disease, and heart failure.
Cardiac catheterization is performed using a contrast material which has iodine in it. People allergic to iodine can usually be prepared with adequate medications a day in advance, thus minimizing the risk of any allergies.
Blood thinning medications other than aspirin or Ticlid may need to be held off for a few days prior to angiography.
Angiography is performed under local anesthesia with a gentle sedative.
Angiography is traditionally performed through the femoral artery which is accessed via the groin. However, angiography can as easily be performed through the branchial artery in either arm.
Typically, a catheter, about 2 mm in diameter, is introduced through the artery which establishes a painless access for detailed angiography.
At the conclusion of the procedure, this catheter is pulled out and pressure is applied to achieve hemostasis. The pressure is applied for roughly 15 to 30 minutes. Bed rest is required for 6 hours. After that resting, activity is resumed gradually and patients are discharged home 7 to 8 hours after angiography if there is no complication. Patients with diabetes may need additional precautions including a change in their diabetic medications on an individual basis. It is important to discuss allergies with your physician prior to angiography, especially if there are any allergies to iodine or seafood.

Balloon/Stent Angioplasty

Transluminal angioplasty refers to a technique of dilating (opening) significantly blocked arteries from inside; thus avoiding the need for much more extensive surgical intervention. The quest for therapeutic catheterization started in 1929 when Forssman in Germany inserted a catheter into his own heart via a vein from the left arm in an attempt to deliver medications safely into the heart. After a lull of several years, the technique of catheterization and subsequently coronary angiography was developed in the '40's, '50's, an '60's. In 1964 Charles Dotter attempted to stretch open blocked limb arteries using incrementally larger catheters. The technique evolved gradually over the ensuing years, and the first balloon angioplasty was performed during a heart bypass surgery in 1977 in San Francisco. Since those early days, the technique has evolved dramatically, allowing well-trained interventional cardiologists to dilate a large proportion of the blocked arteries. A number of complimentary technologies have also been developed that include excimer laser angioplasty, directional atherectomy, and stent angioplasty. For a given blockage, one or a combination of the above technologies may be considered appropriate. In balloon angioplasty a deflated balloon catheter is placed across the narrowed segment of the artery and then the balloon is inflated to a high pressure; thus transmitting circumferential pressure and compressing the plaque. This "normalizes" the internal luminal size. Over the ensuing several weeks to months, "natural" healing takes place. Depending upon a multitude of factors, about one-third of the arteries re-narrow and need a repeat angioplasty; about two-thirds of the arteries tend to stay open on an indefinite basis. Excimer laser angioplasty refers to a technique in which a laser beam is transmitted via contact to the plaque that helps evaporate the blockage; thus creating a channel. Supplemental balloon dilatation is performed in this channel to achieve an adequate internal luminal size. Directional atherectomy refers to a technique in which part of the blockage is mechanically shaved off and removed from inside the artery and then additional balloon angioplasty or stent angioplasty may be needed. In certain specialized circumstances, when the blockages are very long and hard, a rotating diamond burr (rotational angioplasty) can be used. Increasingly, thin metal coils are being used to expand the blocked arteries. Typically, a thin, slotted, stainless steel, metal tube is crimped over a balloon and taken across the narrowed segment of the artery; then high pressure is used to inflate the balloon and, thus, a slotted, metal tube (stent) is deployed across the narrowed segment. The stent provides a mechanical scaffolding and prevents the possible complete blockage of the artery that may occur due to unexpected tear with balloon angioplasty. The use of stent angioplasty, when considered appropriate, improves the chances of success, both immediately and on a long-term basis. Special blood thinning medications are necessary with stent angioplasty. Under most circumstances, following balloon angioplasty/stent angioplasty patients are observed for a period of 24 hours and usually discharged home the next day. Under most circumstances, routine activities can be resumed within a few days of the balloon/stent angioplasty; however, heavy strenuous activities are not advised following stent angioplasty for about four weeks. Also, a dental workup is not recommended for two to three months after stent angioplasty and, if it is necessary, precautionary antibiotics are advised. The stents do not interfere with metal detectors in airports.

Benefits of PTCA/Stent PTCA

"Normalization" of internal arterial lumen with a minimally invasive technique.
Brief downtime.
Avoidance of extensive surgery.
Easy to repeat if necessary.
Symptomatic relief with improvement in quality.
Reduction in medications following a successful outcome.

Potential Complications

Major complications occur in 1-5% of patients undergoing the above procedures. These include:

Risk of total occlusion of the artery with possible heart attack and bypass surgery on an emergency basis.
Risk of stroke during catheterization.
Less than 0.5% chance of loss of life.
Bleeding complications.
Possibility of deterioration of kidney function, especially in people with underlying kidney disease and diabetes. This is related to the contrast material necessary for angiography/ angioplasty.

Local Perspective

The first case of intracoronary stent angioplasty at Bakersfield was performed by Dr. Bhambi on this date. Dr. Bhambi has had extensive experience in complex angioplasty procedures including excimer laser angioplasty, directional atherectomy, and research studies in stent angioplasty during his fellowship at Cedars-Sinai Medical Center. Because of his training, Dr. Bhambi was exclusively appointed to develop the stent angioplasty programs, at both San Joaquin and Memorial Hospitals. Dr. Bhambi is a proctor for Johnson & Johnson Company that makes the stents and has been actively involved in training a number of cardiologists in the technique of stent angioplasty.

Brijesh Bhambi, MD, FACC - is board certified in Internal Medicine, Subspecialty Board of Cardiolovascular Diseases. Doctor Bhambi is a Fellow of the American College of Cardiology and Fellow of the American College of Angiology.