PTCA or Coronary Balloon Angioplasty

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What is Angioplasty?

Angioplasty is a technique used to dilate or open up an area of arterial blockage with the help of a catheter that has an inflatable small sausage-shaped balloon at its tip.
Since the balloon catheter is introduced through the skin of the groin, and sometimes the arm (percutaneous = through the skin), is placed within a blood vessel (transluminal = in the channel or lumen of a blood vessel) and is applied in the treatment of coronary arteries, the technique is also called PTCA or Percutaneous Transluminal Coronary Angioplasty.

PTCA or Angioplasty

The heart is supplied by three major coronary arteries and their branches (as described in the cardiac cath section). Atherosclerosis produces discrete (confined) or scattered areas of blockage within a coronary artery. When the blockages are large enough, they reduce blood supply to the heart muscle and produces angina or chest discomfort. Some patients with coronary artery disease may require surgery. Many patients with serious disease or those who fail on medical therapy are treated with a "needle hole" or "percutaneous" (through the skin) procedure that is performed in the cardiac cath laboratory. Angioplasty is one of these procedures. It was introduced to the world by Dr. Andreas Gruentzig in the mid to late 1970's and was widely and exclusively used for over a decade. Today, it has been replaced by coronary stenting in nearly 90% of cases. POBA or "poor old balloon angioplasty" as the only form of catheter treatment is usually reserved for very small arteries or when a stent cannot be delivered to the blockage. However, it is still frequently used prior to coronary artery stenting to open up a blocked artery and allow easier insertion of the stent.

Angioplasty Approach

In the cardiac cath procedure section, we discussed how a hollow tube or catheter is inserted through a needle hole in the artery and the tip is guided to the opening or begining of the coronary artery where the tip is seated and dye is injected to display the narrowing or stenosis of the artery. The PTCA procedure is discussed below.

Angioplasty physically opens the channel of diseased arterial segments (see below), relieves the recurrence of chest pain, increases the quality of life and reduces other complications of the disease. Since it is performed through a little needle hole in the groin (or sometimes the arm) it is much less invasive than surgery and can be repeated more often should the patient develop disease in the same or another coronary artery in the future.

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FAQ

During a Percutaneous coronary angioplasty or PTCA procedure, a thin guide wire with a very soft and flexible tip is introduced through the "guiding catheter" and into the coronary artery.
Heparin or another medication is given intravenously before placing a guide wire into the coronary artery to reduce the likelihood of clots forming during or immediately after the procedure. The effectiveness of the medicine is confirmed with a blood test (ACT). Additional medication may be given during the case to maintain an acceptable ACT level. Aspirin and other pills (Plavix®, Effient® or Ticlid®) may be given. They belong to a class of medications called antiplatelet agents that work by helping to prevent harmful blood clots. Intravenous antiplatelet drugs may also be used in high risk patients or those having a heart attack.
Small injections of the contrast material makes the coronary artery and stenosis temporarily visible. The tip of the wire is passed beyond the coronary stenosis.
This wire now serves as a "guide" or rail over which the balloon catheter can be delivered. The tip of the wire is floppy or flimsy while the rest of the guide wire is stiffer.
A PTCA "balloon catheter" has a deflated sausage-shaped balloon that is located on the tip of the catheter shaft.
The tip of the wire has a small bend or curve. The course of the guide wire is controlled by the cardiologist with the help of a plastic torque device that is screwed on to the outside portion of the wire. The torquer is rotated as the tip is gently advanced across the blockage or stenosis of the artery. The course of the artery is monitored by fluoroscopy
There are two channels within the PTCA catheter. One extends through the catheter shaft and allows it to be "fed" over the guide wire. The other channel connects the balloon to an outside plastic port.
The balloon can be inflated by connecting the outside port to a special hand held syringe pump. A mixture of saline and contrast material is used to inflate the balloon. The contrast material helps to visualize the balloon when it is inflated.
The balloon catheter has metallic markers on both ends of the balloon. This helps the cardiologist know the location of the otherwise "invisible" balloon.
The tip of the balloon catheter is passed over the guide wire and positioned across the lesion or blockage. The metallic markers that are visible by fluoroscopy is usually positioned proximal (before) and distal (beyond) the stenosis. This ensures that a properly slected balloon wil cover the entire length of the blockage.
The empty or deflated sausage-shaped balloon of the PTCA catheter is filled with fluid or inflated. The balloon is kept inflated for thirty or more seconds to open up the blockage. This procedure is repeated several times until an acceptable opening is achieved within the previously blocked artery. Between inflations blood flow is maintained through the coronary artery.
The patient may experience chest discomfort during the balloon inflations. Intravenous sedation is given to keep the patient comfortable.

This page was reviewed and updated on August 28, 2011

Inflation is initially carried out at a pressure of 1 to 2 times that of the atmosphere and then sequential and gradually increased to 8 - 12 and sometimes as high as 20 atmospheres, depending upon the type of balloon that is used. The handheld inflation syringe has markers that are used to determine the pressure. The balloon is kept inflated for 1/2 to 2 minutes and then deflated until the next inflation is used. Intermittent inflation allows blood flow through the artery during the time that the balloon is deflated.
A nitroglycerin solution may be injected into the coronary artery to prevent spasm.
As the balloon is inflated, it compresses the atheroma and plaque that make up the coronary blockage.
During each inflation, the atheroma or plaque is compressed or "squashed" even more. This is continued until the opening of the tube at that level of the blockage becomes closer to the tube not covered with plaque.
Unfortunately, the obstruction material of atherosclerosis is composed of soft fatty atheroma, firm plaque and a medium consistency mixture of the two. The material resists expansion by a balloon in different ways. Soft material is compressed easily while firm matter compresses to a lesser degree and may demonstrate cracks following expansion by a balloon. That is why the opening created by a balloon is not always round and smooth, as shown below:
It is important to remember that the balloon of angioplasty catheters is not made of rubber used in toy balloons. Special material is employed so that the catheter balloon inflates to a predictable size at a given pressure. For example, a particular brand of balloon will open up to a 2 mm diameter with 8 atmospheres of pressure and 2 1/4 mm at 16 atmospheres.
A compliant PTCA balloon will expand to a larger size than a non-compliant balloon when inflated with the same amount of pressure. Non-compliant balloons are used for lesions that are "harder" and more resistant to expansion.

The patient remains awake throughout the procedure and mild sedation is used to ensure relaxation and comfort. The deflated balloon and wire are withdrawn when the cardiologist is satisfied with the results. If the result is unsatisfactory, a second balloon or even a stent may be considered.
Final cine angiograms or video x-ray recordings are taken upon completion of the case. The guiding catheter is then withdrawn.
The sheath is secured to the groin with a suture and the patient is sent to his or her room or the recovery area.
As noted earlier, Heparin or another medication is given intravenously before placing a guide wire into the coronary artery. This reduces the likelihood of clots forming during or immediately after the procedure.
The sheath is removed when the effect of Heparin wears off. This is determined by obtaining ACT blood tests at specified intervals. Pressure is applied to the groin with a clamp. Once it is confirmed that there is no bleeding, a sandbag or ice bag is placed over the groin.
After approximately 6 hours, the patient is ambulated or allowed to walk with assistance and is usually discharged the following morning. A Band-Aid or small dressing is applied over the tiny needle hole. Slight bruising around the site is not uncommon.
In some labs, a sealant or closure device is applied in the cath lab after removal of the sheath and the patient may be allowed to ambulate in 2-3 hours. The patient can also ambulate earlier if the arm approach is used.
For a description of the equipment, preparation and experiences during the procedure, please review the cardiac cath section.

How long does the procedure take?

It can take anywhere from 30 minutes to a three hours to perform the entire case.
The duration is dependent upon the technical difficulty of the case and the number of balloon catheters that have to be employed.

How safe is the procedure?

In the hands of experienced cardiologists, and with availability of modern day technology, it is estimated that the risk of death during an angioplasty procedure is usually less than 1% and probably closer to 0.1% (1/1000), while the chance of requiring emergency bypass surgery is around 2% or less. It is a relatively safe procedure and is carried out all over the world. An "out patient" or an inpatient uncomplicated angioplasty usually require 23 hours or less of hospitalization after the procedure.
The risk of a other serious complication is estimated to be less than 4-6 per thousand. The risk of a heart attack and bleeding that requires a blood transfusion is increased when compared to cardiac cath. However, the risks are relatively low and acceptable in most cases when one balances the potential benefit against the expected risk (risk-benefit ratio).
The aggravation of kidney function (particularly in diabetics and those with prior kidney disease) is higher than that expected with cardiac cath because of the larger amount of contrast material that is usually required. In such cases, the cardiologist takes extra precautions to prevent this possible complication.
The risk of requiring emergency coronary bypass surgery ranges from 2-4%. The risk of death from emergency bypass surgery for failed angioplasty is higher than the risk in patients who undergo elective or non-emergency surgery.
The risk of restenosis, complications and mortality (death rate) is higher when angioplasty is compared to stenting, except in cases where angioplasty is used to treat restenosis of a previous stent. In such cases the risk of complications and need for emergency surgery is probably equivalent.

What is the risk of restenosis?

Restenosis is described as recurrence of blockage after performance of a percutaneous coronary intervention (PCI)
Restenosis following coronary angioplasty may occur within 3-6 months, in approximately 30-60% of cases.