In this article we will look at:
- What are stents and what is stent insertion?
- Eligibility for coronary stenting
- How is coronary stenting performed?
- Risks of undergoing the coronary stenting procedure
- Benefits of undergoing the coronary stenting procedure
- Alternatives to coronary stenting
- Pre-procedure guidelines before undergoing coronary stenting
- Possible complications of coronary stenting
- Post-procedure guidelines after undergoing coronary stenting
- Recovery period after undergoing a coronary stenting procedure
- Are the results of coronary stenting permanent?
- Is the coronary stenting a success?
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What are stents and what is stent insertion?
Stents are small expandable mesh tubes that are inserted to keep clogged arteries open after a balloon angioplasty procedure. This is a minimally invasive procedure to restore proper blood flow through the heart. The stent is inserted during, or immediately, after balloon angioplasty, which prevents the artery from closing up again.
There are two types of stents:
- Bare-metal stents: These stents are expanded during angioplasty and act as a column which keeps the once clogged blood vessels continuously open. Unlike drug-releasing stents, bare-metal stents do not have any special coating. Once the blood vessel heals, tissue begins to grow around the stent, holding it in place. Though, there is a risk of scar tissue growing along the blood vessel lining, which can increase the risk of re-clogging.
- Drug-eluting (releasing) stents: These stents have a polymer coating over the mesh that emits a drug over time to help prevent the growth of scar tissue along the blood vessel lining. This helps the blood vessel remain smooth, open, and keeps the blockage from recurring and ensures good blood flow.
Depending on the patient's medical condition, the duration of the procedure may take 30 minutes to 3 hours. The cost of the procedure ranges between Rs. 1,00,000 to Rs. 3,60,000 in India.
Generally, mild sedation is required for the procedure, though in some cases, based on the patient’s health, general anesthesia may be used.
The average hospital stay for a patient undergoing angioplasty with stent insertion is 2 days or less. Some patients may not even require overnight stay at the hospital.
Am I eligible for coronary stenting?
You are eligible for coronary stenting if:
- you suffer from physical symptoms which are interfering with the quality of your life due to coronary artery clogging such as, shortness of breath, profound weakness when exerting yourself physically, continuous discomfort in the chest.
- you suffer from stenosis, which is a condition in which a coronary artery becomes narrow due to a buildup of fatty plaque within it.
- your main coronary artery on the left is blocked more than 70%, in which case you may need to opt for angioplasty or a surgery whether or not you are symptomatic.
- the narrowing of coronary arteries has led to poor heart functions.
- the narrowing of arteries have led to reduced blood flow and angina that medicines are not able to help.
- if you suffer from an obstruction in blood flow, 50% or more in the left main coronary artery, or 70% or more in the major epicardial (a branch blood vessel, also called epicardial coronary artery, that lies on the surface of the heart) vessel. Your blood flow is measured by non-invasive testing.
Not every blockage can be treated with angioplasty, especially if you have several blockages or the blockages located in certain inaccessible locations. In such cases, angioplasty is not recommended. Also, you need to inform your doctor if you are pregnant.
Please Note: Eligibility criteria for various medical procedures differs from patient to patient and depends on their general health, medical history, and medical conditions. Please consult a doctor to know more about your eligibility or ineligibility for any medical procedure.
How is coronary stenting performed?
A coronary stenting procedure involves the following steps:
- You are positioned on an examination table.
- You may be connected to monitors that track your heart rate, blood pressure, and pulse during the procedure.
- An intravenous (IV) line is inserted into a vein in your hand or arm so that medication can be administered to you intravenously.
- Depending on your medical condition, an appropriate type of anesthesia will be administered.
- Disinfectants are applied on the area of your body (the upper leg or the wrist) where the catheter (a thin flexible tube) is to be inserted. The area is then covered with a surgical drape.
- Once the anesthesia takes effect, the cardiologist begins the angioplasty procedure by making a very small skin incision at the site (upper leg or the wrist).
- If the upper leg is chosen, the cardiologist inserts a thin tube called catheter through the femoral artery. (The femoral artery is the second largest artery in the body and is located in the thigh. The primary function of this artery is to supply blood to the lower section of the body.)
If the wrist is chosen, the cardiologist inserts the catheter through the radial artery.
(The radial artery is a major artery in the human forearm. It supplies oxygenated blood from the lungs to the arm and hand.)
- The cardiologist carefully guides the catheter through the arteries into the blocked area of the heart, more specifically into the blocked part of the coronary artery.
(As arteries have no nerve endings you will not feel anything while the catheter is inserted through the artery.)
- Once the catheter reaches the narrowed artery, the cardiologist injects a special dye (also called radiographic contrast agent) through the catheter, which highlights the arteries. The X-ray machine is used to capture the images of the outlined arteries which reveal the location of the narrowing.
(This special dye shows the shape and size of the blocks in the arteries prominently in an x-ray camera, which keeps projecting the live images of the arteries onto a monitor.)
- The cardiologist then inserts an X-Ray guided wire with an attached deflated balloon enclosed within a stent, through the catheter, into the blocked area.
- He inflates and deflates the balloon several times. This repetitive action opens up the narrowed artery and the plaque is compressed against the arterial walls. The inflated balloon also expands the artery wall, improving the blood flow.
- X-rays are taken to determine how much the blood flow has improved. When your cardiologist is satisfied that the artery has been opened enough, he slowly removes the balloon, the guidewire, and the catheter, and leaves behind the stent in an expanded position.
The expanded stent which is left behind helps to keep the artery open at all times prevents reclosure, so that the blood can flow through uninhibitedly.
What risks will I face while undergoing coronary stenting?
The risks of undergoing coronary stenting may include:
- Injury to the artery while inserting the catheter
- Heavy bleeding from the catheter insertion site that may require special medication or a blood transfusion
- Risk of stroke while performing angioplasty
- Blood clotting
- Clogging of the inside of the stent (in-stent restenosis)
- Irregular heartbeat (arrhythmias)
After the procedure is over some patients may face the risks of:
- An allergic reaction due to anesthesia or the contrast dye that is injected
- An allergic reaction to the drug used in a drug-eluting stent, the stent material
How will I benefit from coronary stenting?
The benefits of coronary stenting are many:
- Drug-eluting stents prevent the need for more invasive procedures, such as coronary artery bypass surgery. These stents reduce the risk of arteries getting re-blocked, and therefore, also the need for repeat angioplasty procedures which often carry the risk of complications such as heart attack and stroke.
- This procedure is usually done using local anesthesia, rather than general anesthesia. Thus, no risks related to general anesthesia are involved such as nausea, vomiting, high blood pressure etc.
- This is a minimally invasive procedure in which no surgical incision is needed, only a small nick on the skin is made that does not even require suturing.
- The recovery time after angioplasty with stent insertion is far less than any other surgical procedure. An extended stay at the hospital may or may not be required depending on the patient's condition.
An added advantage of coronary stenting is that it is much affordable, and low risk compared to surgical interventions such as bypass surgery.
What are my alternatives to coronary stenting?
The alternatives to coronary stenting include:
- Medications and lifestyle changes, if your condition isn't severe or immediately life-threatening.
The doctor may prescribe medications, such as beta-blockers, nitrates, calcium channel blockers, and lifestyle changes such as doing away with the habit of smoking, taking a heart-healthy diet and exercising. These changes can effectively alleviate your heart condition.
- Balloon Angioplasty
- Laser Angioplasty
- Coronary Artery Bypass Surgery
What are the pre-procedure guidelines I should follow for coronary stenting?
The usual pre-operative guidelines which are followed prior to a coronary stenting procedure are:
- The doctor will ask for your complete medical history prior to the procedure which includes your current medication and any known allergies.
- A complete physical examination by your doctor to ensure you are in a stable condition to undergo the procedure. You may have to undergo blood tests or other diagnostic tests. The doctor will also ask for your medical history prior to the procedure.
- The tests performed include:
- chest x-ray
- electrocardiogram (EKG)
- blood tests
- an imaging test called coronary angiogram
- Your doctor will give you instructions about eating or drinking before angioplasty. You'll be advised not to take anything orally (food, liquids or tablets) 6 to 8 hours prior to the scheduled procedure.
- Woman need to inform the cardiologist and X-ray technologist if she is pregnant or likely to be pregnant. (It is not advisable to take an X-Ray or undergo any radiological testings during pregnancy. Additional care will be provided for pregnant women, so as to not expose the fetus to radiation).
- You should let your doctor know about all the medications you take, including herbal supplements, and blood thinners. You will be asked to stop taking blood thinners for a certain period prior to the procedure.
- You should let the doctor know if you are allergic to any medicines, as some people are allergic to the drug used in a drug-eluting stent, the stent material, or the x-ray dye. Therefore, if you suffer from asthma or are allergic to any substance such as iodine, latex or rubber gloves, X-ray dye, eggs, meat, specific vegetables and fruits, or any form of seafood such as shellfish, inform the doctor prior to the procedure.
- You need to continue taking your blood pressure related medicines.
- If you smoke or consume alcohol you may be advised by the doctor to not do so for at least a week or two prior to the procedure. You may be advised to stop smoking altogether as this is a major cause of atherosclerosis.
What are the complications of coronary stenting?
Coronary stenting is generally safe, however, in some cases, complications may occur. Please consult your cardiologist to be aware of all the possible complications that may occur, such as:
- Recurring blockages, although most of these arteries can be opened again successfully. The blockages can also re-occur after balloon angioplasty or laser angioplasty.
- A relatively rare complication associated with angioplasty called occlusion or abrupt vessel closure which occurs in the area treated by the balloon angioplasty. This blockage occurs within 24 hours of the procedure. If it happens, medication is administered into the artery to dissolve clots followed by angioplasty or stenting. In certain cases, emergency bypass surgery may be needed.
- Damage to the blood vessel through which the catheter is guided, as well as bruising or bleeding at the puncture site.
- Damage to a heart valve.
- Damage to a blood vessel
- The contrast dye used during this procedure may cause renal failure, though your cardiologist generally checks your renal function before performing this procedure.
- Heart attack.
- Irregular heartbeat (arrhythmias)
- Stroke (this is rare)
Please consult your cardiologist to know all the possible complications that may occur.
What are post-procedure guidelines I need to follow after undergoing a angioplasty with stent insertion procedure?
Once the procedure is over you can return home and take post-procedure care which includes:
- taking plenty of rest and drinking plenty of fluids.
- avoiding any form strenuous exercise and lifting heavy objects till your doctor tells you it is safe.
- avoiding sexual activities upto 5 days.
- avoiding lifting anything heavy with the arm into which the catheter was inserted.
- quit smoking (permanently).
- promptly reporting to your doctor if you see a change in colour in your leg, pain or a warm feeling in the area where the catheter was inserted
- taking your medicines religiously, especially the medicines given for anti-clotting. Do not stop taking the anti-clotting and anti-platelet medicines without consulting your doctor. They are highly essential to keep strokes and heart attacks at bay.
- changing to a healthy diet post the procedure and inculcating healthy lifestyle changes which include avoiding smoking and drinking. This can work wonders in preventing and even reversing coronary disorders.
- limit usage of any staircase for the first 2 to 3 days, and if possible avoid it altogether.
- making sure the area where the catheter was inserted does not get wet for 48 hours after the procedure.
- going for a general physical check-up one week after the procedure to get an ECG done, get the blood pressure checked and undergo some laboratory tests.
- opting for a cardiac rehabilitation programme offered in many major hospitals of India. Cardiac rehabilitation programmes can be of twelve weeks which include monitored exercises 3 to four times a week.
- report to the doctor immediately if you experience pain in the chest or in the leg or wrist, allergic reaction to medications, experiencing dizziness or weakness, fever, and chills.
To take care of the incision site:
- follow the directions of your doctor on how often the dressing needs to be changed.
- if sudden bleeding occurs at the site of the incision, lie down and gently put pressure on your incision site for about 30 minutes. If the bleeding does not stop, return to the hospital or call the medical emergency service.
What is the recovery period after undergoing an angioplasty with stent insertion?
In general, patients are able to walk around within a few hours after undergoing the angioplasty procedure, depending on how the procedure went and where the catheter was placed.
Complete recovery takes place within 5 - 7 days.
Are the results of angioplasty with stent insertion permanent?
Many people have experienced relief from heart problems after being successfully treated with drug-eluting stents, thus preventing the need for more invasive procedures, such as coronary artery bypass surgery. The reduced risk of narrowing of arteries due to drug-eluting stents reduces the need for repeat angioplasty procedures.
If angioplasty with stent insertion is coupled with healthy lifestyle changes, then there is a less likelihood of recurrence.
How do I know if the angioplasty with stent insertion procedure I underwent is a success?
The imaging tests taken during post-procedure follow-up visits will clearly show the volume of blood flow in the artery. Normal/adequate blood flow is indicative of a successful outcome of the procedure. Repeat procedures may be necessary if indicated.
More Cardiology Related Topics
People interested in this topic also read:
1. Stettler C, Allemann S, Wandel S et al. Drug-eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis. 2018. Available at: http://www.bmj.com/content/337/bmj.a1331. Accessed February 23, 2018.
2. Hannan EL, Wu C, Walford G, M, Culliford AT, Gold JP, Smith C R, Higgins RSD, Carlson RE, Jones RH. Drug-Eluting Stents vs. Coronary-Artery Bypass Grafting in Multivessel Coronary Disease [Internet]. http://www.nejm.org/. 2018 [cited 23 February 2018]. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa071804
3. Gobić D e. Drug-Coated Balloon Versus Drug-Eluting Stent in Primary Percutaneous Coronary Intervention: A Feasibility Study. - PubMed - NCBI [Internet]. Ncbi.nlm.nih.gov. 2018 [cited 23 February 2018]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29208251?_ga=2.105251779.1304300378.1518492937-1119665951.1516249862
4. Stettler C, Wandel S, Allemann S, Kastrati A, Morice M, Schömig A et al. Outcomes associated with drug-eluting (coated) and bare-metal stents: a collaborative network meta-analysis [Internet]. 2018 [cited 23 February 2018]. Available from: https://www.sciencedirect.com/science/article/pii/S0140673607614445
Questions answered by trusted doctors
Did you know?
Invention of the coronary stent
The word “stent” is derived from the name of its creator, Charles Stent (1807-1885), an English dentist who invented a compound to produce dentures, skin grafts and hollow tubes (which is a metal coronary stent) etc. He rose to fame when he suggested using the material he discovered to coat the underwater trans-Atlantic cable, which had broken several times as a result of corrosion by seawater.
Coronary stent design
Originally coronary stents are solid, hollow tubes. The openings (which are lattice-like or have a chicken-coop wire effect) are later created with laser cuts. Newer stents are braided from individual thin metal wires. This design is intended to keep the stent flexible enough to navigate the twists and turns of the coronary arteries.
Experiencing angina after stent placement
Up to 30% of the patients who have had stents implanted or open heart bypass surgery still experience angina later.
Angioplasty is not generally recommended for blockages below 70%
Angioplasty is not generally recommended for blockages below 70%. There is no proven benefit in implanting a stent in an area of blockage that does not impair blood flow to the heart muscle. These blockages require only medications and lifestyle changes to be treated successfully.
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