Angioplasty, coronary

A coronary angioplasty is a procedure used to widen blocked or narrowed coronary arteries (the main blood vessels supplying the heart).

The term 'angioplasty' means using a balloon to stretch open a narrowed or blocked artery. However, most modern angioplasty procedures also involve inserting a short wire-mesh tube, called a stent, into the artery during the procedure. The stent is left in place permanently to allow blood to flow more freely.

Coronary angioplasty is sometimes known as percutaneous transluminal coronary angioplasty (PTCA). The combination of coronary angioplasty with stenting is usually referred to as percutaneous coronary intervention (PCI).

When a coronary angioplasty is used

Like all organs in the body, the heart needs a constant supply of blood. This is supplied by the coronary arteries.

In older people, these arteries can become narrowed and hardened (known as atherosclerosis), which can cause coronary heart disease.

If the flow of blood to the heart becomes restricted, it can lead to chest pain known as angina, which is usually triggered by physical activity or stress.

While angina can often be treated with medication, a coronary angioplasty may be required to restore the blood supply to the heart in severe cases where medication is ineffective.

Coronary angioplasties are also often used as an emergency treatment after a heart attack.

What are the benefits of a coronary angioplasty?

In most cases, the blood flow through the coronary arteries improves after an angioplasty. Many people find their symptoms get significantly better and they’re able to do more than they could before the procedure.

If you've had a heart attack, an angioplasty can increase your chances of surviving more than clot-busting medication (thrombolysis). The procedure can also reduce your chances of having another heart attack in the future.

• How a coronary Angioplasty carried out?

• Before having a coronary angioplasty you'll need an assessment to make sure the operation is possible.

  This also gives you an opportunity to discuss any concerns with your cardiologist (heart specialist).

  A procedure called cardiac catheterisation and coronary angiography is used to examine the arteries near your heart to make sure the operation is possible.

  A long, flexible plastic tube called a catheter (about the width of the lead in a pencil) is inserted into a blood vessel, either in your groin or arm. 

  The tip of the catheter is guided to your heart, or the arteries supplying your heart, using an X-ray. A special fluid that shows up on X-rays, known as contrast medium, is injected through the catheter. The resulting pictures are called angiograms.

  During your pre-operative assessment, you may also have blood tests and a general health check to ensure you're suitable for surgery.

  You'll be asked not to eat or drink anything for four to six hours before a coronary angioplasty.

  You'll usually be able to take most medications as normal up to the day of the procedure, with the exception of blood-thinning medication (anticoagulants), such as:

  • warfarin
  • dabigatran
  • rivaroxaban
  • apixaban
  • edoxaban

  You may also need to alter the timing of any diabetes medication you take. Your medical team can give you more information about this.

  Read more about preparing for an operation.

  The operation

  A coronary angioplasty usually takes place in a room called a catheterisation laboratory, rather than in an operating theatre. This is a room fitted with X-ray equipment to allow the doctor to monitor the procedure on a screen.

  A coronary angioplasty usually takes between 30 minutes and two hours, although it can take longer.

  You'll be asked to lie on your back on an X-ray table. You'll be linked up to a heart monitor and given a local anaesthetic to numb your skin. An intravenous (IV) line will also be inserted into a vein, in case you need to have painkillers or a sedative.

  The cardiologist then makes a small incision in the skin of your groin, wrist or arm, over an artery where your pulse can be felt. A small tube called a sheath is inserted into the artery to keep it open during the procedure.

  A catheter is passed through the sheath and guided along the artery into the opening of your left or right coronary artery.

  A thin, flexible wire is then passed down the inside of the catheter to beyond the narrowed area. A small, sausage-shaped balloon is passed over the wire to the narrowed area and inflated for about 20-30 seconds. This squashes the fatty material on the inside walls of the artery to widen it. This may be done several times.

  While the balloon is inflated, the artery will be completely blocked and you may have some chest pain. However, this is normal and is nothing to worry about. The pain should go away when the balloon is deflated. Ask your cardiologist for pain medication if you find it uncomfortable.

  You shouldn't feel anything else as the catheter moves through the artery, but you may feel an occasional missed or extra heartbeat. This is nothing to worry about and is completely normal.

  If you're having a stent inserted (see below), it will be already fitted onto a balloon and opens up as the balloon is inflated. The stent will be left inside your artery after the balloon is deflated and removed.

  When the operation is finished, the cardiologist will check that your artery is wide enough to allow blood to flow through more easily. This is done by monitoring a small amount of contrast dye as it flows through the artery.

  The balloon, wire, catheter and sheath are then removed and any bleeding is stopped with a dissolvable plug or firm pressure. In some cases, the sheath is left in place for a few hours or overnight before being removed.

  Going home

  A coronary angioplasty often involves an overnight stay in hospital, but many people can go home on the same day if the procedure is straightforward.

  After the operation, you won't be able to drive for one week, so you'll need to arrange for someone to drive you home from hospital.

  Read more about recovering from a coronary angioplasty.

  Stents

  A stent is a short, wire-mesh tube that acts like a scaffold to help keep your artery open. There are two main types of stent:

  • bare metal (uncoated) stent
  • drug-eluting stent – which is coated with medication that reduces the risk of the artery becoming blocked again

  The biggest drawback of using bare metal stents is that, in around a third of cases, the arteries begin to narrow again. This is because the immune system sees the stent as a foreign body and attacks it, causing swelling and excessive tissue growth around the stent.

  It's possible to avoid this problem by using drug-eluting stents. These are coated with medication that reduces the body’s abnormal response and tissue growth. However, this also delays the healing of the coronary artery around the stent and means it's vitally important to keep taking blood thinning treatment (see below) for up to one year after the procedure. This helps reduce the risk of a blood clot blocking the stent suddenly and causing a heart attack.

  Once a drug-eluting stent is in place, the medication is released over time into the area most likely to become blocked again. The two most researched types of medication are:

  • "-limus" medications (such as sirolimus, everolimus and zotarolimus) – which have previously been used to prevent rejection in organ transplants
  • paclitaxel – which inhibits cell growth and is commonly used in chemotherapy

  The use of drug-eluting stents has reduced the rate of arteries re-narrowing from around one third to less than one in 10 and they are now used in more than 70% of stent procedures.

  The National Institute for Health and Care Excellence (NICE) recommends that drug-eluting stents should be considered if the artery being treated is less than 3mm in diameter or the affected section of the artery is longer than 15mm, because evidence suggests the risk of re-narrowing is highest in these cases.

  Before your procedure, discuss the benefits and risks of each type of stent with your cardiologist.

  If you have a stent, you'll also need to take certain medications to help reduce the risk of blood clots forming around the stent. These include:

  • aspirin, taken every morning for life
  • clopidogrel, taken for one to 12 months depending on whether you have had a bare metal or drug-eluting stent, or whether you have had a heart attack
  • prasugrel or ticagrelor, which are used as alternatives to clopidogrel in people who have been treated for a heart attack

• Recovering from an Angioplasty

• After having a planned (non-emergency) coronary angioplasty, you'll normally be able to leave hospital the same day or following day. Arrange for someone to take you home.

  Before you leave hospital, you should be given advice on:

  • any medication you need to take (see below)
  • improving your diet and lifestyle
  • wound care and hygiene advice during your recovery

  You may also be given a date for a follow-up appointment to check on your progress.

  You may have a bruise under the skin where the catheter was inserted. This isn't serious, but it may be sore for a few days. Occasionally, the wound can become infected. Keep an eye on it to check it's healing properly.

  Your chest may also feel tender after the procedure, but this is normal and usually passes in a few days. If necessary, you can take paracetamol to relieve any pain.

  Activities

  Your hospital team can usually advise you about how long it will take to recover and if there are any activities you need to avoid in the meantime.

  In most cases, you'll be advised to avoid heavy lifting and strenuous activities for about a week, or until the wound has healed.

  Driving

  You shouldn't drive a car for a week after having a coronary angioplasty.

  If you drive a heavy vehicle for a living, such as a lorry or a bus, you must inform the DVLA that you've had a coronary angioplasty. They'll arrange further testing before you can return to work.

  You should be able to drive again as long as you meet the requirements of an exercise/function test and you don't have another disqualifying health condition.

  GOV.UK has more information on coronary angioplasty and driving.

  Work

  If you had a planned (non-emergency) coronary angioplasty, you should be able to return to work after a week.

  However, if you've had an emergency angioplasty following a heart attack, it may be several weeks or months before you recover fully and are able to return to work.

  Sex

  If your sex life was previously affected by angina, you may be able to have a more active sex life as soon as you feel ready after a coronary angioplasty.

  If you have any concerns, speak to your GP. According to experts, having sex is the equivalent of climbing a couple of flights of stairs in terms of the strain it puts on your heart.

  Medication and further treatment

  Most people need to take blood-thinning medications for up to one year after having an angioplasty. This is usually a combination of low-dose aspirin and one of the following medications: 

  • clopidogrel
  • prasugrel
  • ticagrelor

  It's very important you follow your medication schedule. If you stop your medication early, it greatly increases your risk of a heart attack caused by the treated artery becoming blocked.

  The course of clopidogrel, prasugrel or ticagrelor will usually be withdrawn after about a year, but most people need to continue taking low-dose aspirin for the rest of their life.

  You may need to have another angioplasty if your artery becomes blocked again and your angina symptoms return. Alternatively, you may need a coronary artery bypass graft (CABG).

  Cardiac rehabilitation

  Cardiac rehabilitation should be offered if you've had a heart operation. This programme aims to help you recover from the procedure and get back to everyday life as quickly as possible.

  Your cardiac rehabilitation programme will begin when you're in hospital. You should also be invited back for another session taking place within 10 days of leaving hospital.

  A member of the cardiac rehabilitation team will visit you in hospital and provide detailed information about:

  • your state of health
  • the type of treatment you received
  • what medications you'll need when you leave hospital
  • what specific risk factors are thought to have contributed to needing the operation
  • what lifestyle changes you can make to address those risk factors

  Once you've completed your rehabilitation programme, it's important you continue to take regular exercise and lead a healthy lifestyle (see below). This helps protect your heart and reduce the risk of further heart-related problems.

  The British Heart Foundation has more information about cardiac rehabilitation.

  Lifestyle changes

  If you have a coronary angioplasty, it's still important to take steps to reduce your risk of having further problems in the future. This may include:

  • trying to lose weight if you're overweight
  • stopping smoking if you smoke
  • eating a healthy diet with low levels of fat and salt
  • being active and exercising regularly

  Smoking and being overweight are two of the main causes of heart disease. They also make treatment less likely to work.

  See healthy hearts for more lifestyle advice.

• Risks

• As with all types of surgery, coronary angioplasty carries a risk of complications. However, the risk of serious problems is small.

  Complications that can occur during or after an angioplasty include:

  • bleeding or bruising under the skin where the catheter was inserted – estimated to occur in more than one in every 20 cases
  • damage to the artery where the sheath was inserted – estimated to occur in less than one in every 100 cases
  • allergic reaction to the contrast agent used during the procedure – estimated to occur in less than one in every 100 cases
  • damage to an artery in the heart – estimated to occur in less than one in every 350 cases
  • excessive bleeding requiring a blood transfusion – estimated to occur in less than one in every 100 cases
  • heart attack, stroke or death – estimated to occur in less than one in every 100 cases

  Who's most at risk?

  Several factors increase your risk of experiencing these complications. These include:

  • your age – the older you are, the higher the risk
  • whether the procedure was planned (for angina), or is emergency treatment for or after a heart attack – emergency treatment is always riskier because there's less time to plan it and the patient is already unwell
  • whether you have kidney disease – the contrast agent used during an angioplasty can occasionally cause further damage to the kidneys
  • whether more than one coronary artery has become blocked – this is known as multi-vessel disease
  • whether you have a history of serious heart disease, including heart failure

  Your cardiology team can give you more information about your individual circumstances and level of risk.

• Alternatives

• The most widely used surgical alternative to a coronary angioplasty is a coronary artery bypass graft (CABG).

  Coronary artery bypass graft

  A coronary artery bypass graft is surgery to bypass a blockage in an artery. This is done using segments of healthy blood vessel, called grafts, taken from other parts of the body.

  Segments of vein or artery from your legs, arms or chest are used to create a new channel through which blood can be directed past the blocked part of the artery. This allows more blood to get through into the heart muscle.

  Complications of CABG are uncommon, but are potentially serious. They include:

  • a heart attack – estimated to occur in one in every 15-50 cases
  • a stroke – estimated to occur in one in every 50 cases

  A CABG is usually recommended when multiple coronary arteries have become blocked and narrowed. However, it's invasive surgery so may not be suitable for people who are particularly frail and in poor health.

  A CABG may also be used if the anatomy of the blood vessels near your heart is abnormal because a coronary angioplasty may not be possible in these cases.

  Which procedure is best?

  You may not always be able to choose between having a coronary angioplasty or a CABG, but if you are it's important to be aware of the advantages and disadvantages of each technique.

  As a coronary angioplasty is minimally invasive, you'll recover from the effects of the operation quicker than you will from a CABG. Coronary angioplasty usually has a smaller risk of complications, but there's a chance you'll need further treatment because the affected artery may narrow again.

  However, the number of people who need further surgery has fallen because of the use of drug-eluting stents. See how a coronary angioplasty is performed for more information about these.

  CABG has a longer recovery time than coronary angioplasty and a higher risk of complications. However, only one person in 10 who has a CABG requires further treatment. Also, some evidence suggests that CABG is usually a more effective treatment option for people who are over 65 years of age and particularly for people with diabetes.

  You should discuss the benefits and risks of both types of treatment with your cardiologist and cardiac surgeon before making a decision.

  Alternative types of coronary angioplasty

  If a conventional coronary angioplasty is unsuitable because the deposits in your coronary arteries are very hard, you may be offered a different type of angioplasty procedure that involves destroying or cutting away these deposits.

  Examples of this type of procedure include:

  • percutaneous transluminal coronary rotational atherectomy (PTCRA) – where a small rotating device is used to remove the fatty deposit
  • percutaneous laser coronary angioplasty – where a laser is used to burn through the fatty deposit

  These procedures are usually used when the coronary artery has a high level of calcium in it. Calcium makes the artery very hard and can prevent balloons or stents expanding properly to relieve the narrowing.

  Once the deposit has been removed, the artery is treated with balloons and stents as during a conventional angioplasty procedure.

• Case study - 'I suddenly felt like I was being kicked in the chest'

• Lynn Connor had a coronary angioplasty after she had a heart attack. A quick diagnosis and treatment saved her life.

  "I'd just got back from holiday in Cyprus and was feeling on top of the world. I had given all the grandchildren their presents, when I suddenly felt like I was being kicked in the chest. I knew I had to get to a doctor quickly.

  "My GP knew immediately that I was having a heart attack and called an ambulance. I was lucky that I was given lifesaving, clot-busting drugs by the paramedics on the way to the hospital. That night, I was given an angioplasty, where a sort of balloon is put into your coronary artery to open it up. Five stents (which are like a stainless steel mesh) were then inserted to hold the artery open.

  "Nobody knows what caused the attack, but my dad died of one when he was 66. Some people say it was because I smoked 20 cigarettes a day for 40 years. It could have been stress – my granddaughter had been diagnosed with cancer the same year. I believe it was probably a combination of things.

  "After the operation, walking just 10 yards left me exhausted. Even eating was tiring. After a while, I went on a cardiac rehabilitation programme. It started off very gently. First, I did warm-up exercises, then I progressed to step-ups and the cycling machine, until finally I could go on the treadmill. I couldn't have done any of this without the help of my cardiac nurse, Lou, who was brilliant and very reassuring.

  "I've always eaten a pretty healthy diet, but now I exercise more than I used to. I love swimming and I try to go every day. I’ve also given up smoking.

  "I feel incredibly happy that I'm alive. Everyone else I've known who had a heart attack has died, but now I know that there can be life after a heart attack."