Angioplasty & stents

Angioplasty is a procedure done under local anaesthetic, in order to dilate (widen) or unblock narrowed or blocked arteries. Coronary angioplasty is performed by threading a long thin tube (catheter), at the tip of which is a small inflatable balloon, from an artery in the arm or leg to the narrowed artery in the heart.

The deflated balloon is passed into the narrowed or blocked arterial segment and the balloon is inflated and then deflated, in order to restore normal blood flow along the artery. In many cases, a short cylinder of expandable wire mesh (or “stent”) is first placed over the deflated balloon, so that the stent can be left in place within the artery, holding the dilated segment open. Angioplasty may not be suitable for everyone.

A doctor demonstrates the equipment used in an angioplasty

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So a patient is having what we call an angioplasty we need to get to the arteries, which are the tubes that supply the blood to the body, and we are, essentially, going against the flow of blood to reach the heart and this is the sort of plastic tube that might be put into the wrist or the artery at the top of the leg in order for us to get into the blood supply.

This is a catheter, which is a tube with a hollow inside. Basically, that passes through the catheter that it’s in the either the wrist artery or the leg artery and it passes through back up and, essentially, we reach the heart with this catheter and by injecting dye we can look at the heart arteries and see where the blockage is. Through this we can then pass a very fine wire to open the artery and then use our balloons and stent treatments to keep the artery open.

So this is what a stent would appear like. There is a metal spring, if you like, just mounted on to a balloon.

So it’s a stent there. Okay there’d be a wire and a balloon going into the heart artery.

So that’s the balloon, which has now been expanded and that would be inside the artery and when we let the balloon down, and this is the stent, which would stay inside the artery and act as scaffolding to keep the artery open.

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In some situations, angioplasty can be performed as the initial (“primary”) treatment for a heart attack, within the first few hours of the onset of its symptoms. Primary angioplasty is the same procedure as a coronary angioplasty but called a primary angioplasty if given as an emergency (see ‘Initial treatments for heart attacks’ and ‘Pre-hospital care in the ambulance for a heart attack’).

John talks of his experience of receiving primary angioplasty.

Age at interview 67

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Age at diagnosis 67

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Do you remember much about the procedure [primary angioplasty]?

Oh I remember it completely yes.

Can you take me through that?

Yes. So other than the sort of being slightly uncomfortable because of the way my arm was, I remember them feeling and they talked to me about exactly what they were going to do all the way through. They sprayed my groin, and shaved it and obviously the spray was a local anaesthetic or something. And then they, I just felt a slightly sharp pain as they cut into the artery and then went up through that. And I was, could watch on the television, the same television screen that the surgeons oh sorry the cardiologists, were looking at and was watching this go through. I’d seen it on television as a process but slightly surreal watching somebody pushing something into your own heart on this. So it, and it was over quite quickly. So my main feeling was of slight discomfort rather than anything else and gratitude of course because the team was superb. And I was then taken out of the Cath lab and I had to wait in the corridor for five minutes I think it was on the trolley. And then was taken up to the Cardiac Care Unit and again superb. I mean the nursing staff were absolutely brilliant there.

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Heart attack patients need to be treated within two hours to make primary angioplasty effective and to avoid further damage to the heart muscle.

The cardiologist at the hospital told James that he needed primary angioplasty without delay to…

Age at interview 63

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Age at diagnosis 62

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They explained that my heart had had; the blood flow in my heart had actually in two cases nearly blocked completely. It was channelling through a different channel to make my heart continue to; the longer they left this procedure the longer, sorry, the larger the damage to my heart, that is how it was explained to me which is why I had absolutely no objections to anything they said and to be honest because obviously I knew of people who had had heart attacks and to what they’d suffered and I had no doubts about having that operation on that day, no doubts at all because they explained it in such a way that if it left, if I left it any longer the damage could increase. They needed to do it immediately, the sooner they do the operation after a heart attack the less damage. The longer they leave it then the damage can increase.

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His hospital notes show that John’s primary angioplasty and the fitting of a stent was done in…

Age at interview 67

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Age at diagnosis 67

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As we got to the [Hospital name] they pulled up and as the doors opened a registrar got in, introduced himself to me and said, Do you mind if I ask you a few questions as we are making our way to the Cath lab?’ And so he was running alongside the trolley. At the time it seemed like it was only seconds but in fact their log which I had a copy of, they sent me a copy of their log, showed it was 3 minutes to get me from the ambulance to the Cath lab [catherisation laboratory]. We went into the Cath lab which is like a really 21st Century, almost 22nd Century lot of robotic equipment in there, massive amount of people. I think there were probably 8 people in there or something like that’ radiographers, surgeons and so on. I noticed this one guy who was already capped and gowned and he said, Oh Mr. [Name] you’ve had a heart attack, my name is Professor [Name] which filled me full of confidence at being dealt with by a professor and he said, We are going to go in through your groin and stent you. He said, There are three arteries which are suspect but only one of them is, you know, urgent. He said, So we are going to do that one which is the really urgent one and then you will have the option of either while you are here having them done or you could come back as an outpatient because they’re not urgent that we deal with the other two. They are mild in comparison.

So you had the angioplasty and the stent?

Yes

At the same time?

Yes, yes. So he went in and they blew up the artery with the balloon and then they put a stent in. The next thing, I mean it was slightly uncomfortable because I was still in my working clothes and they had sort of not even taken my shirt off. They’d sort of ripped open some of the button and I ended up being told, you know, Keep your hands away from there because this is a sterile area but it was amazing. I have nothing but praise for the team.

There was no time to do anything.

No [laugh]. But anyway with, and again their log shows that within fourteen minutes of entering the Cath lab I was out again with a stent fitted which is phenomenal.

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In other situations, other treatments are given initially, after which angioplasty may or may not be used, either before the patient goes home from hospital, or at some later time. One man was transferred to a specialist hospital to have a stent fitted before he was discharged home after his heart attack. Another man had an angioplasty after thrombolytic drugs hadn’t worked. Others were discharged from hospital to wait for a date for angioplasty, usually several months later.

Had angioplasty when use of clot-busting drugs had failed. Describes signing the consent forms…

Age at interview 63

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Age at diagnosis 62

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The A&E service was first rate; effective, efficient and reassuring. I was seen immediately and in what seemed like no time at all they diagnosed a heart attack in progress, explained what they proposed to do, got the necessary signatures and gave me an extremely welcome pain killing injection.

Did they admit you to cardiology?

Yes they did. The initial approach was to attempt to dissolve the obstruction in the heart artery and this appeared to be successful. After a couple of days I was moved to a general heart surgery ward.

The next day I felt like death warmed up and decided that the thing I needed was a brisk shower and a shave. Afterwards I felt much better for an hour or so, but the pain returned in my arms, back and chest. Clearly the treatment hadn’t stuck.

You had a heart attack that day, a second one?

Well, I think I must have done. It certainly felt like it. That was the official view because I later discovered that a message had been sent to my wife saying I’d had another heart attack and had been moved back to cardiology.

As I understand it, the initial procedure they’d used could be attempted twice, so they had a second go at dissolving the clot. My next memory was being told that it hadn’t worked and they needed to move on to Plan B.

Were you getting enough information about what was going on?

Oh yes. My recollection might be coloured to some extent by things I have heard or read since, but as I recall the medical team were meticulous about consultation and agreement.

There was this form requiring signatures, which at the time struck me as being bureaucratic, but which I suppose is just part of the usual audit trail ensuring patients have been properly informed and medical staff provided some protection in the event of things going wrong despite best endeavours.

The doctor doing this liaison certainly got across in general terms what was involved in an angioplasty and stenting, and the risks of damage to a blood vessel or inducing a stroke. I’m sure I was also aware of possible recourse to more major surgery as a matter of urgency if things did not go according to plan.

I deliberately took ten minutes or so to get my chemically scrambled brains to think through the situation. So information provision linked with formal agreement to undertake a medical procedure simply can’t be faulted in this instance.

How did you make the decision to have an angioplasty?

Well, in truth there wasn’t much of a decision to be made. I had complete confidence in the medical team and they had a clear course of action in mind. There weren’t any options on offer to agonise about. In those circumstances you’d be foolish to do other than go with the flow. Always provided you had fully understood what you had let yourself in for.

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Before primary angioplasty/angioplasty is done, patients need to sign a consent form. Some of the people we spoke to said that the doctor explained very clearly the risks and possible outcomes of the procedure before they signed the form.
In some cases, people went on to have a second, non-emergency angioplasty and were fitted with one or more stents that were not seen as urgent at the time of primary angioplasty. In Mervyn’s case, his consultant used medication to improve an artery found to be slightly blocked.

The consultant told Mervyn that he still had an artery slightly blocked but that the medication…

Age at interview 76

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Age at diagnosis 73

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After you were discharged from hospital did you go back to see the consultant or not?

Mervyn’ Yes. I went once to see the consultant. And that’s when he said to me, that I didn’t know anything about, he said, I’ve still got one artery marginally

Mervvn’s wife’ No moderately

Mervyn’ Moderately blocked.

And but he assured me that the medication would sort it out. But I didn’t know that straight after I had the heart attack but I was told when. I think it was the final assessment from the [Hopsital name] that I was told. So it’s a strange thing really I still don’t know the condition of my heart really. it’s not like if you cut your finger you can say, Oh it’s getting better. But you’ve had a heart attack and you don’t really, you can’t see that it’s getting better although I did, I did a research project didn’t I? I had to go back and have MRI scans.

I had about 4 or 5 over a period of a year, something like that and that was for a research. And I think the person that was running it said that my, the damage to the heart muscle had more or less recovered to about 95% or something like that.

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Most people said angioplasty was very straightforward and not painful, or only a little uncomfortable. For one man the worst part of the procedure was needing to lie flat for several hours afterwards, to prevent any bleeding from the artery in his leg, and to ensure his blood pressure was stable and he was not having any adverse reactions to the medication he had been given. One man, who was transferred from his local hospital to a regional cardiac centre after an acute heart attack, explains that a balloon pump was used to support the heart during angioplasty.

Describes having angioplasty and says it was less painful than she had expected.

Age at interview 37

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Age at diagnosis 36

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The angioplasty was, which I had at the specialist hospital they just, it’s similar to an angiogram but, obviously, they did treatment on this one. What basically, what they do is they just shave your groin area where they insert a tube like a catheter which they run up through your artery and up towards your heart;

And, and then they insert, it’s like a little, tiny balloon which they blow up to open up the artery and then they left in a little mesh stent to keep the artery open. You’re, you’re awake while they’re doing it. Its uncomfortable but its not, its not painful, its just, theres a discomfort;

Its a bit like going to the dentist I’d say, the same sort but I was terrified of having that done because, obviously, it was just like, you know, something that you don’t, never want to have done in your lifetime and then, the fact that I was like 37 and about to have that done, I was really terrified but the team, they were as good as gold and just, they do it every day so to them its nothing;

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A balloon pump was used to support the heart during angioplasty.

Age at interview 69

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Age at diagnosis 66

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And as I’ve mentioned I had angioplasty and most people thought I would have had a stent put in but apparently I didn’t have a stent. The doctor did later say that more or less something to the effect that he wouldn’t sort of do what he had to do again because obviously time had gone on and it had taken so long to do what he had to do but I had a balloon pump inserted which was there to assist the heart to work.

It didn’t take over the work of the heart apparently but it did assist the heart until everything in the heart itself started to take over it’s own work.

I can remember hearing just this sound which was so peculiar and all I could relate it to was the sound of the generator which a lot of caravans have to power the electrical supply to the caravan and I said, ‘What the devils a generator doing at the end of the ward?’ and my wife just said, ‘That’s the thing that’s keeping you alive. And it was just a little unit and as time went on I didn’t sort of hear it running but it just sounded like a small generator.

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One woman who had quite a lot of discomfort immediately after the procedure said it didn’t last long.

She describes what having angioplasty was like.

Age at interview 63

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Age at diagnosis 63

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Well I wasn’t scared about it. I did find out quite a lot about it before the procedure so and the nurses and the doctor did actually explain to me what was going on. Was a bit surprised to find it was just down in the x-ray department, as opposed in a theatre. So it seemed to be very low key and I think that kind of puts you in a low key mood.

The doctors were there and they just explained that they were going to put the [stent] through the femoral artery. The [TV monitor] was there, so I spent my time watching the [screen].

Then they went in and when he showed me the heart, he said, ‘you can see that the actual artery is blocked. He told me which one it was but I can’t remember at the moment and then he explained that he was looking at it and then they were going to push the stent up and blow it up.

They did give me an injection just to calm me down a little. I wasn’t particularly agitated but its impossible to be perfectly calm, when you know they’re going in to your heart. If they’re going in to a muscle or something its a different thought but there they are actually going in to ones heart.

It is a thought so I had a bit of a tranquilising drug just to calm me down and I just watched them put in the stent and blow up the balloon and take it out.

I did have quite a lot of pain after the process had finished. I had a morphine injection because the pain was quite severe and that was it. I don’t know how long it took, half an hour or maybe more or less I was back in the ward and felt good.

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Alan said that after having primary angioplasty and stent fitted he felt normal’ again.

Age at interview 62

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Age at diagnosis 62

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Well like I felt normal. I really felt normal after that. Even when I was on. I mean I’d still got the pain going to the hospital because they gave that, whatever you, in my arm and then but once I got back home I felt as though I’d had nothing happen to me. You know, I just felt normal.

Were you in pain after you left the

After I came out of hospital I had a few days in pain, yeah but whether that was anything to do with that or not I don’t know but I mean I’ve not had pain. Because I mean it’s hard to say. I mean I don’t know about heart attacks but it wasn’t. I didn’t have a pain. It was just like somebody was pushing me.Not like any real pain you’d think like but I’ve had a few pains that have been proper pains since I had it done but as I say whether it’s anything to do with that I don’t know but.

But after the surgery were you in pain?

No

No?

No, none at all. I could actually, you could actually dare I say, the only thing I didn’t feel the needle. I just felt the tingling sensation and that was all. But actually I still, I mean I knew something was wrong but then all of a sudden it was gone. So that must have been when the artery probably cleared what was going off and. Yeah no I couldn’t believe it, you know.

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The time people waited for a follow up appointment after primary angioplasty varied. The people we talked to have experienced waits of a couple of months to six months. In at least one case, the appointment was brought forward due to the onset of symptoms (e.g. breathlessness). But some people had to wait several months for their follow up appointment and felt apprehensive about it.

When discharged from hospital, Alan was disappointed to hear that his cardiology follow-up…

Age at interview 62

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So when is your next appointment in hospital?

Alan’ July

Alan’s wife’ Not until July

July so that will be?

Alan’s wife’ Six months after.That’s what I thought was. I realise they are busy don’t get me wrong or anything like that but it seems like a long time to me when you think what you’ve had. I know there are probably thousands of heart attacks, I realise that like, but when they were actually talking to me I am sure they said to me, It would be 5 to 6 weeks they’d be getting in touch with you to come back just to make sure that you are getting along alright. But obviously, you know, it was 6 months.

Have you phoned them and asked why July?

Alan’ No I mean when I spoke to the lady about going for my rehabilitation thing as well they seemed to think it was quite normal.

Alan’s wife’ I mentioned it to the lady who I spoke to when I rang [Hospital name] and she said, Oh yeah that’s probably quite normal. Then I said we were expecting a check up in 6 weeks, that’s what they told us and she said, Oh well I don’t think that happens very often. That was that.

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The cardiac rehabilitation nurse arranged for Stanley to see the consultant sooner than…

Age at interview 59

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Age at diagnosis 59

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I should have been seeing him [consultant] in October but it’s been brought forward to tomorrow because I still get quite out of breath.

You’re breathless?

Yeah

OK.

And the cardiac, the rehab nurse, cardiac rehab nurse at [Hospital name] I think she’s had the appointment brought forward, you know, because I don’t think I should still be out of breath like I am.

What makes you feel breathless?

Just talking can. You know if I’ve, you know, I can feel myself getting a bit breathless now.

I feel like I’ve been talking longer than I should without taking a breath, do you know what I mean? I have to [intake of breath] but you know, it does it after a short sentence. I do, I do get a bit breathless but I don’t know whether that is because I’ve stopped smoking because I did get a bit breathless before the heart attack. I was a bit wheezy after I stopped smoking.

Yeah

So I don’t know whether it’s that or whether it’s, you know, effects of the heart attack I don’t know.

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The benefits of angioplasty may not be permanent so that it may have to be done again or coronary bypass surgery may be necessary. One man who had angioplasty two years ago, was beginning to experience angina and was waiting to have another angiogram (see ‘Diagnosing a heart attack’) for information about angiograms.

Coronary artery bypass surgery

Coronary artery bypass surgery may be needed for some people who have had heart attacks. Coronary artery bypass surgery, also known as coronary artery bypass...