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Coronary Stenting

Definition

The procedure involves the placement of a stent, which is a mesh, metal tube placed in an artery in the heart (a coronary artery) to help keep the artery open after an angioplasty procedure.

In April 2003 the US Food and Drug Administration (FDA) approved a new type of coronary stent, called a drug-eluting stent. This type of stent is coated with a medication that is slowly released and helps decrease the rate of reblockage in the artery in which it is inserted.

Early experience with the stent suggested that there may be an increased early risk of clotting with the stent. This seems to be confirmed by review of four years of data gathered from clinical trials.

A small percentage of patients treated with drug-eluting stents, especially those with blockages in more than one vessel and/or diabetes , might be at higher risk for reblockage after one year since the time the stent was put in. This, in turn, may lead to an increased rate of heart attacks in this group. Talk to your doctor to see whether those types of stents might be appropriate for you.

Coronary Artery: Stent Procedure

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Parts of the Body Involved

  • Coronary arteries
  • An artery in the groin
  • Arteries leading to the heart

Reasons for Procedure

To hold open a blocked artery in the heart, allowing more normal blood flow through that artery

Risk Factors for Complications During the Procedure

What to Expect

Prior to Procedure

Your doctor will likely do the following:

  • Blood tests
  • Electrocardiogram (ECG, EKG)—a test that records the heart's activity by measuring electrical currents through the heart muscle
  • Chest x-ray

In the days leading up to your procedure:

  • The night before, eat a light meal and do not eat or drink anything after midnight.
  • You may be asked to shower the morning of your procedure, and you may be given special antibacterial soap to use.
  • Arrange for a ride to and from the procedure.
  • Arrange for help at home for the first few days after your procedure.

During the Procedure

  • IV fluids
  • Sedation
  • Anesthesia
  • Blood thinner to decrease blood clots from forming
  • Pulse oximetry to monitor blood oxygen levels

Anesthesia

Local anesthesia will be injected into the area in your groin where the catheter will be inserted.

Description of the Procedure

The area of your groin where the catheter will be inserted is shaved, swabbed with an antibacterial solution, and numbed with local anesthetic. (This procedure can also be performed, though less commonly, through an artery in the arm.) The doctor inserts a needle into a groin artery, and a wire is passed through the needle. The wire is guided through the arterial system until it reaches the blocked artery in the heart. Next, a soft, flexible catheter tube is slipped over the wire and threaded up to the blockage.

This procedure is monitored using a continuous x-ray image called fluoroscopy. Dye can be injected through the catheter into the arteries of the heart to make any blockages more visible via fluoroscopy. Once the blockage is reached, a small balloon at the tip of the catheter is quickly inflated and deflated, stretching the artery open. The collapsed stent, a small metal mesh tube, is then inserted through the arterial system to the area of the blockage. The balloon is inflated to expand the stent to its full size. The stent is left in place to hold the vessel walls open, and the deflated balloon, catheter, and wire are removed. A bandage is placed over the groin area.

After Procedure

You'll need to lie flat on your back, keeping your legs still for about six hours after the procedure. You may have a sandbag placed over the area in your groin where the catheter was inserted. This puts pressure on the artery and prevents bleeding.

How Long Will It Take?

30 minutes to three hours

Will It Hurt?

The local anesthetic should adequately numb the area where the catheter is inserted, so the entry site shouldn't be painful. However, you may feel a burning sensation when the area is anesthetized and may feel pressure when the catheters are manipulated. Some people have a flushing feeling or nausea when the dye is injected. Also, you may feel some chest pain during inflation of the balloon.

Possible Complications

  • Allergic reaction to x-ray dye
  • Bleeding at the point of catheter insertion
  • Perforation of the artery in the heart, requiring immediate emergency bypass surgery
  • Spasm of the artery
  • Heart arrhythmia (abnormal heart beats)
  • Heart attack
  • Stroke
  • Blood clots may form and travel through the arteries, causing stroke, heart attack, kidney damage, breathing difficulties, damage to an arm or leg, or intestinal damage
  • Infection

Average Hospital Stay

0-2 days

Postoperative Care

  • To minimize pain and soreness, you can place ice on your groin for 15-20 minutes each hour for the first two days. After this time, switch to a heating pad or hot water bottle.
  • Take blood-thinning medications as prescribed by your doctor. This may be aspirin or another medication, such as warfarin.
  • To lower your risk of recurrent blockages in your coronary arteries and further heart disease, make lifestyle changes, including eating a healthier diet, exercising regularly, and managing stress.
  • You may need to undergo periodic stress tests to identify any recurrent blockages early.
  • Always inform new doctors or other medical personnel that you have a coronary stent in place. Some medical procedures need to be modified or avoided for people with coronary stents, particularly MRI scans.

Outcome

Your artery should be considerably more open, allowing better blood flow to feed the heart muscle. This may mean that you'll no longer have chest pain that you previously experienced, or it may mean that your tolerance for exercise will increase. Sometimes, however, the procedure isn't successful, or the artery narrows again, in which case you may require repeat angioplasty or coronary artery bypass grafting (CABG).

In a review of 23 studies, researchers found that patients who received CABG had more angina relief and a lower rate of having another procedure to restore blood flow. This is compared to patients who received percutaneous coronary intervention (PCI), such as balloon angioplasty or coronary stenting . *

Call Your Doctor If Any of the Following Occurs

  • Chest pain
  • Arm or leg becomes painful, blue, cold, numb, tingly, swollen, or increasingly bruised
  • Cough, shortness of breath, chest pain, or severe nausea or vomiting
  • Redness, swelling, increasing pain, excessive bleeding, or discharge from the insertion site in your groin
  • Extreme sweating or nausea
  • Signs of infection, including fever and chills

RESOURCES:

American Heart Association
http://www.americanheart.org

University of Maryland Medical Center
http://www.umm.edu

CANADIAN RESOURCES:

Canadian Cardiovascular Society
http://www.ccs.ca/home/index_e.aspx

Heart and Stroke Foundation of Canada
http://ww2.heartandstroke.ca/Page.asp?PageID=24

References:

American Heart Association website. Available at: http://www.americanheart.org . Accessed October 14, 2005.

Camenzind E. Treatment of in-stent restenosis—back to the future? N Engl J of Med. 2006;355:2149-2151. Available at: http://content.nejm.org/cgi/content/short/NEJMe068215 . Accessed November 13, 2006.

Harrison's Principles of Internal Medicine . 16th ed. 2004.

Heart Disease: A Textbook of Cardiovascular Medicine . 5th ed. Philadelphia, PA: WB Saunders; 1997.

Shuchman M. Trading restenosis for thrombosis? New questions about drug-eluting stents. N Engl J of Med . 2006;355(19):1949-1952.

What are angioplasty and coronary stents? University of Maryland Medical Center website. Available at: http://www.umm.edu/patiented/articles/what_angioplasty_coronary_stents_000003_10.htm . Accessed October 14, 2005.

11/7/2007 DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance : Bravata DM, Gienger AL, McDonald KM, et al. Systematic review: the comparative effectiveness of percutaneous coronary interventions and coronary artery bypass graft surgery. Ann Intern Med. 2007 Nov 20. [Epub ahead of print]



Last reviewed November 2007 by J. Peter Oettgen, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.


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