Coronary artery disease (atherosclerosis) is the process of narrowing
of the coronary arteries. Eventually, this can lead to heart attacks and heart failure. Treatment for this condition
include medications to reverse the process. Unfortunately, medications work slowly and incompletely, and additional
treatment is often needed in the form of stents or bypass surgery.
What is an angioplasty and stent?
Angioplasty is the process of placing a balloon in the artery and inflating it with high pressure,
to push cholesterol out of the way. The artery wall becomes distended, but the blockage tends to come back with recoil
or scar tissue. Thus, a metal stent is usually place to help keep the artery open, and prevent any cracking or tearing
of the vessel. These procedures are usually done together. Current stent technology allows for a coating of a
drug on top of the stent to additionally prevent scar formation.
How does my physician choose between stents or bypass surgery?
Your physician will generally recommend stents for 1 or 2 blocked arteries, that are appropriate
size and location for angioplasty. Your physician will generally recommend bypass surgery if there are multiple blockages
or complete blockages, especially if these are long and complex involving branching points. Patients who are older and
have many other medical problems, may not want to undergo bypass surgery, and stents are usually a treatment option.
Some patients may be treated appropriately with either method.
What are the risks?
The risk of angioplasty is higher than of the simple angiogram, and could result in a cracked
artery (dissection), clotting, or heart attack. The risk will depend on the severity of disease, but overall is generally around
1%. However, the risk of a heart attack if the severely blocked arteries are not treated is certainly
higher than 1%.
What is a Rotablader?
This is a special drill that is used in some vessels with extensive disease and calcium buildup.
The drill is inserted into the heart artery over a wire and spins at very high speeds (150,000 rpm). This will
help open the artery before placing a stent.
Do pieces of cholesterol breakoff in the artery?
Yes, sometimes small particles of cholestol and debri may go downstream in the artery.
Usually this does not cause any problems, but sometimes a small amount of heart damage occurs. This may cause chest
pain during or after the procedure, and may cause the blood levels of enzymes to elevate slightly. For very high risk
procedures, a small net is used to catch the large debri particles.
What does it mean if chest pain occurs after a stent?
Some people can feel stretching of the artery from the stent. Sometimes a small amount
of heart damage occurs from debri particles during the procedure, or blocking of a small side vessel. These complications
are well accepted, and do not cause any significant long-term problems. Rarely, the stent that was placed clots and
a larger heart attack can occur. This may occur in about 0.5% of cases, and needs to be treated as soon as possible
with another procedure. Sometimes, persistent chest pain means that another vessel that was not treated is responsible
for the symptoms, or that symptoms are from another cause, such as esophogeal ulcers or muscular
pain.
When can I return to normal activities?
Some patients feel better immediately after the procedure, while other patients may be significantly
deconditioned, and take time to return fully to normal activities. Patients need to be careful not to lift heavy objects
for several days, so the hole introduced into the groin artery does not bleed. Otherwise, most patients may return
to normal activities when they go home. Patients who have had a heart attack may need to have reduced levels of activity
for days or weeks.
What medications are needed after a stent?
Currently, we recommend aspirin and clopidogrel (Plavix) to all patients who have had a stent
placed, unless allergic to these medications. Aspirin may be dosed as 81 mg, 162 mg, or 325 mg. The different
doses all appear equally effective, although there is some increased bleeding at higher doses, and the lower doses are
less well studied. Plavix is usually recommended for 12 months if a coated stent is used (Cypher, Taxus), while
only about 1 month is needed for non-coated stents. Aspirin is recommended indefinitely.
Are the new coated stents better?
Recently, there has been a little controversy regarding the safety of drug-coated stents compared
to the traditional bare-metal stents. The two stents currently on the market, Cypher and Taxus, both reduce the risk
of scar formation after a stent is placed, and therefore, the risk for another procedure. The stents are coated with
a chemical which is released slowly for several months. Initial reports of these stents suggeted
a small increase in the risk of future heart attack or death. However, there have now been 4 published studies in 2007
that show these newer coated stents have similar or even lower rates of death or heart attack than bare metal stents. Currently, we
recommend longer use of blood thinnners such as Plavix after a stent to help avoid complications of stent thrombosis
(clotting). Most cardiologists use drug coated stents for the majority of procedures, as they provide better long
term results. These drug coated stents appear to be cost effective in only certain situations, such as smaller vessels
with longer length of disease and in vein grafts.
