The heart is a muscular organ that pumps oxygen rich blood throughout your body. To function, the heart muscle must also receive oxygen rich blood, which is supplied by the coronary arteries. The coronary arteries originate from the aorta and wrap around the surface of the heart. This extensive network of vessels delivers blood to the heart muscle so that it can carry out its pumping function.

Coronary artery disease occurs when the inner lining of the artery develops an atherosclerotic plaque. Plaque is a complex accumulation of cellular and lipid materials which, over time, can grow and obstruct blood flow. Plaque is also referred to as stenosis, a lesion, or a blockage. All of these terms refer to the process called atherosclerosis.

Chest discomfort (angina) occurs when the heart muscle is deprived of its blood supply. Angina can occur when the artery is partially obstructed by a fixed atherosclerotic plaque (ischemia). This is a situation where the supply of blood to the heart is not adequate for the muscle to do work. When plaque narrows the coronary artery 80-90 percent, angina is likely to occur.

A heart attack (myocardial infarction) occurs when there is abrupt rupture of a plaque. The lesion size increases quickly. A blood clot then forms on the unstable blockage and completely obstructs the flow of blood to the heart muscle supplied by that artery. If the flow is not restored promptly, a portion of the heart muscle dies. Permanent damage occurs and the heart fails to pump blood effectively. Urgent PTCA to restore flow is a definitive treatment during a myocardial infarction.

You will be taken to a specially equipped room in the catheterization lab. After transfer to an X-ray table, heart monitoring equipment will be placed on your chest and blood pressure equipment will be placed on your arm. Intravenous anticoagulation will be given. The PTCA is performed under sterile conditions. You will be draped with sterile sheets and all personnel will be wearing sterile clothing. The area of equipment insertion on your body will be cleansed with a cool antiseptic solution and the cardiologist will inject the area with a local anesthetic. You will experience a momentary stinging sensation quickly followed by numbness.

A sheath is inserted into the artery. Through this sheath, a narrower and longer tube called a guiding catheter is passed to the heart. A contrast agent is injected through the guiding catheter which allows the interventionalist to visualize the coronary arteries. While observing the arteries on X-ray, a steerable guidewire is threaded through the guide catheter and advanced past the narrowed segment of the coronary artery.

A balloon catheter is inserted over the guidewire and positioned at the site of blockage. The balloon is expanded. As it expands, the balloon compresses the fatty deposit (stenosis) against the lining of the artery. It also remodels the artery wall, pushing the walls out and increasing the internal diameter (lumen) of the artery.

A coronary stent may be used after balloon inflation. The decision to stent an artery is based on the location, length, and appearance of the coronary artery under treatment. The stent is mounted on a balloon tipped catheter and inserted into the artery at the site of the original stenosis. When the stent is positioned, the balloon is inflated. The stent expands and becomes firmly pressed into the artery wall. One or more stents may be used in a single artery. Additional balloon inflations may be necessary to completely deploy the stent. The balloon catheter is then removed and the stent will remain permanently in place, keeping the artery open.

The PTCA procedure can take one to two hours, depending on the number of sites dilated and the complexity of your anatomy. Other therapies may include atherectomy (a device used to shave and debulk the lesion), rotoblator (a high speed rotational drill used to pulverize and debulk the lesion), cutting balloon (a special balloon with cutting blades to score the lesion which makes it easier to compress), and intercoronary radiation (localized radiation used to prevent the regrowth of smooth muscle cells within the coronary artery at the PTCA site).

At the end of the procedure, anticoagulation with heparin is discontinued. The sheath is left in the procedure site for approximately four hours while the effect of the heparin on blood coagulation is reversed. Under certain circumstances, another form of intravenous anticoagulation may be continued for approximately 12 hours after the procedure. Special sealing techniques using collagen or sutures are sometimes used at the end of the PTCA. The decision to use these devices is made by the interventional cardiologist at the end of the procedure. You will then be transferred to the Cardiovascular Recovery Unit for overnight observation and monitoring.

The preparation for PTCA is similar to that for the coronary angiogram. An important therapy will be the use of aspirin and/or Plavix prior to intervention. These drugs are beneficial for their anticoagulant properties. Specifically, these drugs inhibit the platelets in your blood which are part of the blood clot cascade. Intravenous anticoagulation may also be initiated prior to angioplasty. Please let your interventional team know if you are allergic to aspirin or Plavix or have a history of bleeding problems.

You will be requested to drink six to eight large glasses of fluid the day prior to your catheterization in order to maintain hydration and reduce the impact the contrast dye may have on your kidneys.
If you are allergic to contrast dye, you will be given a special medication the night prior to and the morning of the PTCA. Please notify us if you have a contrast allergy.

If your procedure is in the first part of the morning, you will be NPO (nothing per mouth) except for medication after midnight. If your procedure is later in the day, then you may have a clear liquid breakfast. Patients with diabetes will be given special instructions.

Prior to PTCA, you will be taken to the cardiovascular holding area. If you are already hospitalized, you will have a consultation with the cardiologist the night before and will have signed the procedural consent. If you are admitted that morning, you will be asked to sign a consent after the procedure has been explained and you will meet the interventional team.

In the holding area, the procedure site will be washed and shaved. This is usually the same site used for the cardiac catheterization. An intravenous line will be started in your arm to provide a route for medication and fluid. Immediately prior to being moved to the cardiac lab, you will be given oral sedation to promote comfort and relaxation. Your family will then be directed to the cardiovascular holding area waiting room.

You will need to remain in bed for approximately 10 hours after the procedure. Four hours after the procedure, a blood test will be taken to determine if the effect of the heparin on the coagulation of your blood has been sufficiently reversed. The sheath is then removed and pressure is held over the arterial puncture site. A small bandage is then applied and you will remain in bed for an additional six hours. If a closure device is used, bed rest after sheath removal is typically two to three hours.

You may have clear liquids as soon as your are admitted to recovery. Solid food will be offered after the sheath removal and as soon as you can tolerate it. If you become uncomfortable, medication will be available upon request. The staff will be checking your heart rhythm, blood pressure, and general well-being very closely. The nurse will also be assessing the procedure site to determine if you are experiencing bleeding complications.

You will stay the night of the procedure in the recovery unit and will then be dismissed at approximately noon the following day. The interventional team will review your procedure and discuss dismissal guidelines which will include a discussion of cardiac risk factors. Follow-up will be one month after the procedure and two to three months thereafter, and will include a thallium test to determine that the PTCA site is still open. You will then have regular annual exams to follow your progress.

The walls of your coronary arteries are made of smooth muscle cells. When the walls are traumatized by PTCA, the artery responds to the localized injury. A complex cascade of events occurs which includes inflammation, healing, and regeneration of tissue. Unfortunately, an aggressive over response can occur. Smooth muscle cells can overgrow and the artery will become narrowed to a degree that symptoms are once again present. This process is called restenosis.

Restenosis can occur up to six months following PTCA. The peak time for it is at two-and-a-half months following the procedure. If restenosis does occur, a repeat procedure may be necessary. Follow-up at one month, and again every two to three months thereafter with noninvasive testing is designed to detect restenosis, even in the absence of anginal symptoms. It is very important to report recurrent symptoms to your cardiologist. If you have a sudden onset of symptoms not relieved with rest and nitroglycerine taken three times at five-minute intervals, you should report to your closest emergency room for immediate treatment.

When the bandage is removed from the puncture site, please assess the puncture area. Look at it and feel around the area with your hand. It is normal to have a small hard knot and some bruising at the site, which may take several weeks to completely disappear. As you stand after the procedure, gravity may pull the bruise (blood under the surface of the skin) down toward your knee, giving the appearance of active bleeding. As long as the bruise is soft to the touch, this is not cause for concern. If you experience mild discomfort in the area after the procedure, you should obtain relief with Tylenol; one or two tablets every four hours. Applying warm, moist heat to the site for 15 minutes four times per day may also be helpful.

• Infection of the puncture site indicated by drainage, redness or fever.
• Pain in the area not controlled by the above pain relief measures.
• A tense, hard area under the puncture site which appears to be increasing in size or is pulsatile. This could indicate active bleeding.

These are all causes for concern and must be managed promptly by calling your local physician or cardiologist.