Angio/Stent

Angioplasty

Dr. William Boden Presents
THE COURAGE TRIAL

Demonstrating that medical management (prescriptions) alone were just as effective as PCTI (angio and stenting) and medical management.

Click Here to see animated PTCA (Buffalo Heart Group)

AHA 2008 Update on Cardiac Stents

Percutaneous coronary intervention (PCI) encompasses a variety of procedures used to treat patients with diseased arteries of the heart, for example, chest pain caused by a build-up of fats, cholesterol, and other substances from the blood (referred to as plaque) that can reduce blood flow to a near trickle, or a heart attack caused by a large blood clot that completely blocks the artery.

Typically, PCI is performed by threading a slender balloon-tipped tube – a catheter – from an artery in the groin to a trouble spot in an artery of the heart (this is referred to as percutaneous transluminal coronary angioplasty – also known as PTCA, coronary artery balloon dilation or balloon angioplasty).  The balloon is then inflated, compressing the plaque and dilating (widening) the narrowed coronary artery so that blood can flow more easily.  This is often accompanied by inserting an expandable metal stent.  Stents are wire mesh tubes used to prop open arteries after PTCA.

ACC/AHA/SCAI Guidelines

A joint 2005 American College of Cardiology/ American Heart Association/ Society for Cardiovascular Angiography and Interventions report gives guidelines for the management of patients undergoing PCI.  The report strongly recommends that PCI should be performed in facilities that have an experienced cardiovascular surgical team available as emergency backup for all procedures.

For patients suffering the crushing pain of a heart attack, a lifesaving trip may be to a hospital prepared to quickly open the blocked artery by inflating a small balloon and inserting a tiny metal structure called a stent to act as permanent scaffolding.  The goal: to restore blood flow to the heart muscle within 90 minutes of the patient’s arrival at the hospital.  Science shows that patients truly benefit from a ‘door-to-balloon time’ of 90 minutes or less.  PCI done in this emergency circumstance is referred to as “primary” PCI.  Other PCI procedures, such as those done to unblock an artery before a heart attack occurs, are referred to as “elective” PCI.

In the past few years, there have been dramatic advances in PCI techniques, devices, and medications.  Drug-eluting stents are among the most notable.  These stents not only prop open the artery, they also slowly release medication that prevents the overgrowth of scar tissue that can renarrow the artery and block blood flow to the heart, a complication known as restenosis.

Additional highlights of the guidelines include:

  • Updated recommendations on using anti-clotting medications, such as clopidogrel, low molecular-  weight heparin, and bivalirudin, before, during, and after PCI;
  • A recommendation that new protective devices be used to trap bits of plaque and blood clots that can break loose during PCI of aging veins from the legs transplanted to the heart during coronary artery bypass surgery;
  • A detailed analysis of the circumstances under which PCI is the best treatment for heart attack;
  • A recommendation for early follow-up of patients who have PCI of the left main coronary artery, which supplies blood to a large portion of the heart muscle; and
  • Strategies for ensuring the best possible patient outcomes and for monitoring quality of care.

Finally, requirements were outlined for institutional and physician competency – including quality assurance and institutional and physician volume of procedures done .

–American Heart Association

Stent Procedure

What is a stent and how is one used?

A stent is a wire metal mesh tube used to prop open an artery during angioplasty. The stent is collapsed to a small diameter and put over a balloon catheter. It’s then moved into the area of the blockage. When the balloon is inflated, the stent expands, locks in place and forms a scaffold. This holds the artery open. The stent stays in the artery permanently, holds it open, improves blood flow to the heart muscle and relieves symptoms (usually chest pain). Within a few weeks of the time the stent was placed, the inside lining of the artery (the endothelium) grows over the metal surface of the stent.

When are stents used?
Stents are used depending on certain features of the artery blockage. This includes the size of the artery and where the blockage is. Stenting is a fairly common procedure; in fact, over 70 percent of coronary angioplasty procedures also include stenting.

What are the advantages of using a stent?
In certain patients, stents reduce the renarrowing that occurs after balloon angioplasty or other procedures that use catheters. Stents also help restore normal blood flow and keep an artery open if it’s been torn or injured by the balloon catheter.

Can stented arteries reclose?
Yes. Reclosure (restenosis) is also a problem with the stent procedure. In recent years doctors have used new types of stents called drug-eluting stents. These are coated with drugs that are slowly released and help keep the blood vessel from reclosing. Stents that are not coated with drugs are called bare metal stents. As detailed below, it is very important that patients with either type of stent take their anti-clotting medicines as directed.

What precautions should be taken after a stent procedure?
Patients who’ve had a stent procedure must take one or more blood-thinning agents. Examples are aspirin and clopidogrel. These medications help reduce the risk of a blood clot developing in the stent and blocking the artery.  Some recent studies have suggested that blood clots may develop later on (more than a year after stent placement) in the drug-eluting stents. Therefore it is really important to stay on your medications as long as your cardiologist recommends. Aspirin is usually recommended for life, and clopidogrel is generally used for one to 12 months (depending on the type of stent) after the procedure. Clopidogrel can cause side effects, so blood tests will be done periodically. If you are taking this medication, it is important that you don’t stop taking it for any reason without consulting your cardiologist who has been treating your coronary artery disease..

For the next four weeks a magnetic resonance imaging (MRI) scan should not be done without a cardiologist’s approval. But metal detectors don’t affect the stent.

–American Heart Association

***IMPORTANT INFORMATION***
The TAXUS® Express2™ Paclitaxel-Eluting Coronary Stent System is intended to be placed into certain types and sizes of coronary arteries to keep them open. This medical device is not appropriate for use in patients who are known to have an allergy to any components of the device (such as the drug paclitaxel, the SIBS polymer coating or 316L stainless steel) or who would otherwise be judged by a medical professional to not be appropriate candidates for placement of coronary stents (such as patients unwilling or unable to take prescribed antiplatelet medicines). Use of coronary stents carries certain risks, including the potential for serious injuries, side effects and even death. The complete FDA-approved directions for use and patient guide (with specific indications, contraindications, precautions and warnings) can be found on the Internet at www.stent.com or a copy can be obtained, free of charge, by calling 1-877-TAXUS-411 (1-877-829-8741). Patients should discuss the benefits and risks with their physicians to determine whether the TAXUS® Stent is an appropriate treatment choice. Federal law restricts this product to sale by or on the order of a physician.

— Boston Scientific

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