ANGIOPLASTY

ANGIOPLASTY (Dr Naomi Hersey and Dr Trevor Cleveland – Sheffield Vascular Institute)

What is angioplasty?

Angioplasty is a minimally invasive procedure used to treat an artery which has become blocked or narrowed. 

What symptoms would I get from a narrow/ blocked vessel? 

Most of the blocked/ narrowed vessels we treat are in the arteries supplying the legs. As a result, the blood flow to the legs is reduced. This can cause pain in the legs, particularly when walking. In a more severe form there may be foot and leg pain at rest, and sometimes ulceration or even gangrene. Angioplasty is performed to relieve or improve these symptoms.

How is angioplasty performed?

The procedure is performed in hospital by an Interventional Radiologist (a doctor specially trained in minimally invasive procedures performed with the help of x-rays and other imaging technologies). The procedure is performed under sterile conditions. The skin will be cleaned and you will be covered with sterile drapes. Local anaesthetic is used to numb the skin and then a small needle is put into an artery in the groin (usually). This needle is then exchanged for a small tube (catheter) which sits inside the artery and allows wires and tubes to be passed into the artery. The radiologist injects x-ray dye into the small tube and uses x-rays to identify the area where the artery is narrow or blocked. The radiologist then passes a thin wire through the narrow or blocked section of artery. Another small tube with a deflated balloon on the end is passed over the wire. When the balloon is in the right place, it is inflated. The balloon is then deflated and removed from the artery. More dye is injected to see if the narrowing or blockage has been successfully treated or if the balloon needs to be reinflated. The radiologist uses x-rays to see where the wires and tubes are throughout the procedure. Sometimes angioplasty is not successful and a wire mesh stent needs to be placed in the artery (see stent information). 

At the end of the procedure the small tube is removed from the groin and a doctor or nurse will need to press on the artery in the groin for around 5-10 minutes. This is to reduce the risk of bleeding and bruising. Sometimes a small device is used to help stop the bleeding more quickly.

How successful is angioplasty?

The success rate is approximately 70%. Patients who are not successfully treated may be offered an open operation to improve their symptoms.

How long will it take? 

This can vary but the procedure usually takes approximately 45-60 minutes.

Will the angioplasty hurt?

The injection of local anaesthetic can be uncomfortable but there should not be any pain once this takes effect. There may be some mild discomfort when the balloon is inflated.

What are the complications?

The risks of angioplasty are very low. However, every procedure has complications. For angioplasty these include:

• Bruising at the site where the artery is punctured.
• Bleeding at the puncture site can occur which may cause a clot to form around the artery (haematoma). If this is very large a small operation may be needed to place a stitch to stop further bleeding..
• Although very rare, it is possible for the artery to become completely blocked. In extreme circumstances this could lead to complete loss of blood supply to the limb.
• Some patients have an allergic reaction to the x-ray dye. This can result in a rash or breathing difficulties. This is usually minor but some people need to take medication to help reaction settle.
• When the balloon is inflated it is possible for the artery to rupture. This is very rare and can sometimes be repaired in the x-ray department with a stent. If this is not possible, an urgent operation may be required to repair the artery.
• When wires and tubes are being passed through the blockage it is possible for small fragments of the material causing the blockage to be dislodged. If this happens they may pass further down the leg and cause another blockage (embolisation). In this circumstance a further operation may be required to remove these fragments. Most times these can be removed without the need for surgery.

ARTERIAL STENTING

(Dr Steven Goode and Dr Trevor Cleveland – Sheffield Vascular Institute)

What is a stent?

Stents are small, strong expandable tubes made of metal mesh which when placed in the blood vessel support its walls from the inside.

When is stenting used/ Why use stent in addition to angioplasty?

Stents are frequently used in conjunction with balloon angioplasty. The angioplasty part of the procedure opens the artery, however if the narrowing cannot be extended sufficiently by means of a balloon dilatation, a stent can be placed into the vessel, to hold the artery open. Sometimes stents are used without prior angioplasty (this is usually because we have found that a stent will be needed in either the short or longer term).  Over time, the artery wall heals around the stent. Another possible benefit of using a stent in addition to angioplasty is that it may decrease the number of procedural complications associated with just angioplasty alone. Sometimes drugs can be attached to stents (Drug Eluting stents) to try to reduce the longer term risk of the artery narrowing where the stent has been placed. Drug eluting stents are frequently used in the heart (coronary stents), but are relatively infrequently used in the remainder of the body.  This is because they have not been shown to be beneficial, are expensive and have a higher risk of some complications (such as sudden stent clotting and blockage).

How is stenting done / Is it a bigger procedure?

The stenting procedure is almost identical to the angioplasty procedure (mentioned above) with a short additional step of deploying the stent in the blood vessel. Initially the stent is delivered on a small diameter delivery system to allow its access into the blood vessel. Once in position within the artery it is expanded to fit the size, shape and bend of the artery. The stent remains in the artery after the procedure to help keep the artery open. Within several weeks the artery wall grows into the stent which usually gets incorporated into the artery wall. In many cases a balloon is still the first treatment step to stretch the artery open, however in some cases implanting a stent is performed without initial balloon dilatation first. 

Following completion of the procedure patients must then lie flat for a period of time. This can vary from hospital to hospital although is usually in the order of 4 hours. There will be some bruising around the catheter puncture site and it may feel a little sore as the anaesthetic wears off. Do ask the nurse for some pain killing tablets for this if it occurs. The doctor will discuss the results of the treatment with you before you go home. A letter will be sent to your General Practitioner explaining the details of the treatment.

WHAT HAPPENS AFTER ANGIOPLASTY AND STENTING?

(Dr Meghna Basal and Dr Trevor Cleveland – Sheffield Vascular Institute)

Post Procedure Advice

Angioplasty or stenting will improve the blood flow in your artery but it will not cure the underlying cause of the blockage - arteries may become narrow again (called restenosis), which is why it is important to follow the advice below.

Any patient with this arterial disease, no matter which arteries are affected, stands to benefit from eating a low fat diet, getting regular exercise, and controlling blood cholesterol.

Angioplasty improves artery blood flow for most people. But, results will depend on where your blockage was and how much blockage you may have in your other arteries. In many cases, you will be prescribed aspirin medication in an attempt to prevent the problem occurring again and to reduce the risk of other artery related diseases such as heart attack and stroke.

If you are a smoker, it is very important that you stop smoking. Smoking causes the arteries to become narrowed and can also cause the blood to clot more rapidly.

The risk of progression or recurrence of disease of the arteries and its complications can be reduced after angioplasty and/or stent insertion by simple lifestyle modifications including: 

1. Weight reduction and exercise
2. Eating a healthy diet, which is low in saturated fats
3. Elimination of smoking
4. Controlling high blood pressure, Diabetes mellitus and high cholesterol. Medications to reduce blood cholesterol (“statins”) are usually recommended and started by either the GP or the hospital doctors