Introduction
Coronary angioplasty, sometimes called PTCA or PCI , is a catheter-based procedure performed by an interventional cardiologist in order to open up a blocked coronary artery and restore blood flow to the heart muscle. Angioplasty now is used as an alternative treatment to coronary artery bypass surgery (CABG) well more than half the time. It is less invasive, less expensive, and faster to perform, with the patient usually returning home the next day. In most cases, following balloon angioplasty, a stent will also be placed to keep the artery open. Angioplasty is performed on an elective basis to treat symptoms of coronary artery disease, such as angina that is not controlled with medication, but it s also performed on an emergency basis to treat a heart attack. It is, in fact, the "gold standard' for the treatment of an acute ST-Elevated Myocardial Infarction (STEMI).

Testing and Diagnosis
In a non-emergency situation, the patient typically has sought medical attention for symptoms such as angina. A medical history is taken, assessment of risk factors is made, and a number of non-invasive tests are performed. For a full explanation of tests used to diagnose coronary artery disease, see the section "Patient Guide to Heart Tests". If tests indicate a high likelihood of obstructive coronary disease, then a cardiac catheterization is scheduled. The patient should inform the doctor or nurse of any known allergies to the dye used in this procedure.

"Cath Possible"
If the "cath" clearly reveals the coronary blockage, this diagnostic test, also called an angiogram, is usually transformed on the spot into the actual angioplasty treatment, adding 30 minutes to the procedure (longer in complex cases). Since all of the steps and hospitalization involved in a catheterization are also necessary for performing an angioplasty, performing both in the same session saves having to go through the entire process again on a different day.

The patient and cardiologist or nurse educator should discuss this option (catheterization with possible angioplasty, or "cath possible") when scheduling the initial catheterization. In the majority of cases, if an angioplasty is performed, a stent will be implanted as well, to keep the artery open, so the patient and cardiologist should also discuss the pros and cons of bare metal and drug-eluting stents before a "cath possible" procedure, especially any allergic reactions to required medications like clopidogrel (Plavix) or aspirin.

The Catheterization Lab
Although the exact protocol varies among hospitals, the patient usually checks in on the day of the catheterization, or the night before. During an initial waiting period, the patient is given some standard tests, signs release forms for the hospital, and may talk to a nurse or cardiologist about the procedure and what to expect. The patient then is put on a gurney, brought to the area outside of the catheterization laboratory ("cath lab") -- a special room that is outfitted with high-resolution fluoroscopic (X-ray) equipment. The patient usually stays in an anteroom where some additional prepping is done. The patient's relatives or support people can usually stay in a waiting room near the cath lab. When it is time for the procedure, the patient is brought into the cath lab itself and transferred to the special table that is part of the fluoroscopy system.

In the cath lab there is a team of medical personnel, there to assist the cardiologist and to make sure the patient is comfortable. During the procedure, which is a kind of "photo session", the patient remains awake and conscious, in order to respond to various instructions from the cardiologist ("take a deep breath", "hold your breath", "cough", etc.). A nurse is available to administer light sedation and pain relief intravenously, as needed, so the patient should communicate his or her needs to the nurse. Should the patient experience discomfort or anxiety, he or she can let the medical staff know.

The Angiogram
A sterile drape is placed over the patient and electrodes to measure heart rhythms are placed on the patients chest. The patient will also be put on an intravenous line (IV) which involves a small needle stick in the arm. The IV is used to administer various medications that may be required during the procedure.

A local anesthetic is injected into the patient's groin, arm or wrist (depending on the chosen entry site). The brachial artery in the arm is seldom used. The usual access point in the U.S. is the groin or femoral artery. However, the use of the radial (wrist) artery has been gaining in the U.S. (it's the default in other countries)

.Once the area is numbed, the introducer needle puncture is made. The cardiologist threads a very thin soft-tipped guide wire and catheter through the entry site and, while watching on the fluoroscopic video screen, follows the main artery in the body, called the aorta, up and around into the opening of the left, or right coronary artery. The patient may feel some discomfort when the needle is first inserted, but should not feel anything during the wire/catheter placement.

Through the hollow catheter, the cardiologist injects a small amount of dye, called contrast, which, when viewed in motion under X-rays, reveals any obstructions or plaques located within the coronary vessels. When the dye is injected, the patient may feel a warm sensation. Views from several angles for both the left and right coronary arteries are recorded. Pictures are also taken as dye is injected into the left ventricle to assess how well the heart muscle is functioning.

From Diagnosis to Intervention
Depending on the number, severity and location of any blockages, the cardiologist will probably do one of four things:

• No blockage -- the patient is negative for coronary artery disease and will be referred back to his/her physician;
• Small blockage -- not severe enough to warrant an intervention -- the patient will be referred for medical therapy to relieve symptoms;
• Multiple blocked arteries with diffuse disease -- the cardiologist may recommend bypass surgery, which is more suited for this situation;
• One or more blocked but accessible arteries - if the blockages can be reached, the cardiologist may continue the procedure as an angioplasty

The Angioplasty
The cardiologist makes some quick equipment changes and threads a thin wire across the area of the blockage. A "rail" or track into the coronary artery has now been established and any number of therapeutic devices can be passed safely and quickly over the wire and positioned precisely at the obstruction. The initial device is usually a tiny balloon which is inflated one or more times. As the blockage is opened, blood flow in the artery is stopped for very brief periods, during which the patient may experience some chest pain. This is normal. When the inflations are done, the balloon is withdrawn.

In most interventions today, a stent is also used, usually following a balloon angioplasty. Unlike the balloon, the stent is expanded but remains in place, serving as a permanent scaffolding for the newly widened artery. In the U.S. most stents used are drug-eluting stents (a.k.a. drug coated stents or "medicated" stents). These devices dispense a small amount of medication over time (currently paclitaxel or sirolimus) to prevent the growth of scar tissue and reclogging of the area. Drug-eluting stents have reduced the incidence of restenosis (reclogging) from 20-30% to single digits.

One consideration in the use of drug-eluting stents is that they require an extended period of antiplatelet therapy after the procedure, usually a combination of aspirin and clopidogrel (Plavix) usually for at least a year. Many physicians recommend continuing Plavix for life. (For more on this issue see: "Late Stent Thrombosis".) Early cessation of these drugs can result in "stent thrombosis": blood clotting at the site of the stent -- this is a very serious complication that is small in percentage but is fatal in almost one-third of the incidents. If possible the patient should make sure they (1) are not allergic to Plavix or aspirin, and (2) will be able to comply with the drug regimen, financially and otherwise.

While balloons and stents are the major devices utilized in catheter-based procedures, there are a number of other devices that also may be used in specific situations, such as intravascular ultrasound or atherectomy catheters.

When the procedure is over, all equipment is removed and the puncture site is compressed in order to stop the bleeding. The patient is moved to a recovery area, sometimes in the Coronary Care Unit (CCU). For many patients, this period is the most uncomfortable part because it is necessary to lie completely still for 4-12 hours during the puncture site compression. To avoid this, several types of vascular closure devices, or "sealants", have been developed and are now being utilized to reduce this period significantly. The patient should ask the cardiologist if a "seal" will be used and discuss the pros and cons of these devices. The compression (or sealing) and recovery procedures are similar whether the patient has had an angioplasty, stent or just a catheterization. Following the procedure, the patient usually remains in the hospital overnight, sometimes longer.

Post Procedure
The cardiologist will prescribe certain medications to be taken for a given period of time after the angioplasty. For a short period, the patient should avoid lifting and other activities that might reopen the puncture site wound. The patient should also drink fluids to flush the dye out of the system. The patient should immediately contact the cardiologist if any pain, shortness of breath or other symptoms develop after the angioplasty. It is normal for the puncture site to be tender and bruised, however, any sign of a purplish hematoma (considered a minor complication) or infection should be reported to the patient's cardiologist.

The first six-month period is the most important because it is usually during this period that restenosis will occur, if it's going to occur at all. It is also vital that patients adhere to any medications prescribed. Often patients are prescribed low-dose aspirin for life -- aspirin has antiplatelet properties which help keep the blood cells from "sticking" together and causing repeat blockages. In addition to aspirin, drug-eluting stent recipients are also prescribed an antiplatelet drug, like clopidogrel (Plavix). Patients need to comply with this regimen and not stop without consulting their physician. It is therefore important that patients do all of the above, as well as whatever they can to reduce the risk factors for coronary artery disease.