Angioplasty — way to normal life

By Dr. Muhammad Hafizullah

For a few moments, which seemed like a century, the pain in the middle of chest was quite intense and even worse - reminiscent of the pain I used to have while exerting. The operating cardiologist would warn me before hand and surely the pain followed his warning and would wane away as predicted.

This pain followed inflation of balloon in the tube that carries blood to my heart and allegedly had blockages. The pain would build up slowly on inflating the balloon and disappear slowly after deflating  the balloon.

Blissfully like a tamed pet it seemed to follow the commands of the master - the cardiologist. This method of blowing of blockages in tubes carrying blood to heart was pioneered by a German cardiologist called Andreas Gruentzig (1939-85) in 1977.

Initially the concept was ridiculed by the leading cardiologists of that time but slowly it was embraced by all. This new procedure practically changed the way patients are managed in the world of cardiology whether presenting in emergency or in stable condition such as unstable angina, heart attack or stable angina.

The number of procedures, requiring balloon and stents, performed in cardiac catheterisation laboratory has increased gradually now being more than the number of bypass surgeries.

Cardiac Catheterisation laboratory as it was called has become more of an 'interventional' workshop where mechanical and electrical problems pertaining to heart are fixed after diagnosis. In three decades the procedure of angioplasty meaning angio — vessel  and plasty - repair has undergone rapid development.

A rare procedure only a few years ago is now one of the most frequently performed interventional procedure in the world of medicine. Associated with lot of uncertainties at the start, the procedure has matured and it can be performed successfully in most cardiac centres around the world.

The procedure entails three important steps: first step is to cross the lesion with a wire to get access, secondly a balloon is delivered on the wire and inflated in the lesion and thirdly a metal scaffolding called stent is placed in the lesion.

Of course there are lots of variations, there are times when a balloon is not used for initial dilatation or at other times a stent is not placed for some specific reasons after a dilatation. After identification of a blockage on conventional angiography or CT angiography, a plan is worked out where approach either radial from the arm or femoral from the leg is considered and chosen. 

Whereas femoral had been a norm for a long time offering a large vessel to puncture and hence ease of employing bigger size catheters and bulky devices and familiarisation of the approach, the downside is to lie straight in bed for nearly twelve hours on the back.

Radial artery is more challenging and may take longer for the operator to perform the procedure but benefit is that catheters and sheath can be pulled out immediately after the procedure and the patient does not have to lie down.

The person can actually walk out of the catheterisation laboratory.

As against a diagnostic catheter-plastic tube, a different catheter called guiding catheter is used for angioplasty, which has wider bore so as to permit balloon and stents to be delivered at the lesion. After gaining access to the coronary artery - tube carrying blood to heart, dye is injected to identify the blockage and measure the length and width with special software.

The choice of guide wire, used to cross the blockage, depends on various factors like severity, location and angulation of blockage.

Different types of wires are available varying from a soft tip to a more firm to cross total blockages. Special wires are used to negotiate tortuous and tricky lesions. Choosing a proper catheter and guide wire can win half the battle.

Some lesions are easy to cross but at other times a seemingly benign lesion may prove to be very challenging and require plenty of time. Having crossed the lesion provides access across the blockage and a balloon is chosen, depending on lesion severity, time of blockage and extent of lesion.

A wide array of balloons mounted on catheters is available. Length of balloon depends upon the extent of the lesion. The balloon, once in place, is inflated with the help of a mixture of dye and water with a special syringe keeping an eye on pressure.

The balloon is inflated under XRay control to see appearance and then disappearance of a waist, implying opening up of the blockage.

My cardiologist sought my preference for the type of stents, bare metal versus drug eluting. A metal scaffolding called stent was introduced in the world of interventional cardiology as a major advance and refinement of the technique.

There were chances of a lesion blocking again after dilatation with a balloon. Initially stent was used when there was risk of collapsing of walls or sub optimal dilatation. Now the use of stent has become a norm. I was informed that there is a huge variety of stents available in the market both of bare metal and drug eluting types.

Both types of stents are essentially the same, the only difference being coating of stent with special drugs to reduce the rate of re-narrowing of vessel called restenosis.

These special drugs reduce the growth of muscles of vessel which regrow with vengeance following dilatation of vessel with balloon or stent. After the procedure, the doctor showed me the pictures on the screen.

Though I had a few episodes of pain in chest during the procedure, after the procedure I felt good. I was fresh and felt proud of the fact that blood was now gushing in my recently opened blood vessels. A technician applied pressure on my wrist and the sheath was pulled immediately after angioplasty.

A tight bandage was applied and I was taken to coronary care unit. I was served water and after some time I had tea and biscuits.

I started chatting with my friends as if nothing was ever wrong with me. I was strictly warned about the future course of action and allowed home the next day.

Two things were made very obvious and they were that I had to walk at least two miles a day on a fast pace covering at least two miles in thirty to forty minutes.

Second important warning was not to stop the medication especially Dispirin and Clopidogrel which are responsible to reduce the thickness of blood. A few days later, putting on my comfortable joggers, I enjoyed walking in the jogging track taking over others.