Catheterization, Angioplasty & Stenting

Your physician has decided that additional diagnostic information is required to determine the best treatment for your heart condition and has referred you for cardiac catheterization. After discussion with your physician it is not uncommon to have additional questions about the procedure. It is not easy to remember every detail during a potentially stressful time in your life. Some patients want to know more than others. This handout is designed to provide information and address the most common questions that arise prior to and after the catheterization procedure. Hopefully you will find it informative and it will help put your mind at ease. It is not intended to replace your physician nor is it all-inclusive and as always we encourage you to speak with your doctor to address any questions you may have.

1. Definitions:

Cardiac Catheterization is the broad term for several related procedures. It includes measuring pressures inside your heart and major blood vessels and making angiograms. An angiogram is an x-ray motion picture of a vascular structure. A coronary angiogram is the x-ray motion picture of your coronary (heart) arteries - the vessels that supply blood to the pumping chamber (left ventricle) of your heart. A left ventriculogram is the motion picture of your heart pumping used to determine it's strength and whether there has been any prior damage to the heart muscle. An angioplasty (or coronary interventional procedure) is a procedure that actually enlarges the blood vessel in areas of narrowing and is usually accomplished with a balloon threaded over a tiny wire placed down the coronary artery. A stent is a metallic device, which can be placed in the area of blockage to buttress the artery open in hopes of preventing any renarrowing due to scar tissue ("restenosis"). A cardiac catheterization is purely a diagnostic procedure which is designed to "make a picture" of the problems affecting your heart to assist your physician in determining treatment options. A coronary interventional procedure (balloon, PTCA, stent) actually "fixes" a blockage. Normally these two related but distinct procedures are done at different times but on occasion may be combined if your physician feels that to be appropriate.

2. The Procedure:

Before the procedure you will meet the technicians who will be assisting the doctor. They are very highly trained usually with years of experience working closely with cardiologists. They are there in part to help put you at ease. You will be brought to the cardiac catheterization laboratory and placed on the "operating table". This table is a common source of complaints because it is narrow and not particularly comfortable but its design allows the doctor to move it into the various positions required. The catheterization technician will clean the entry site (most commonly the groin) with an antibacterial solution and prepare a sterile area for the physician to work. The physician will feel your pulse and use a local anesthetic (usually novocaine like in the dentists office) to numb the area. You will feel a "bee sting" then some mild burning or pressure and after that the remainder of the procedure is generally painless. The doctor will then thread small plastic tubes through the aorta into the heart and the openings of the coronary arteries and inject the contrast dye to make the x-ray motion pictures. With each picture you will be asked to take a deep breath in which moves your diaphragms out of the area of interest and allows for clearer pictures. The doctor may instruct you to cough in certain situations (sometimes the dye causes your heart to slow down temporarily). Because your cooperation increases the picture resolution and the safety of the procedure it is ordinarily accomplished with very little sedation; the amount of sedation varies with each individual patient depending on their degree of anxiety and your doctor will work with you to provide adequate sedation. The diagnostic catheterization usually takes thirty minutes to complete. Some situations may require a longer period depending on the nature of your condition and the information sought. If an angioplasty type procedure need be performed at the same time this is expected to add an hour or so depending on the complexity encountered. These timeframes are estimates and certainly can vary depending on a variety of factors. After the physician has completed the procedure there will be a sheath (a small plastic tube that allows other tubes to be passed through it) remaining in the artery which needs to be removed. Removal of the sheath is accomplished by the catheterization technician by holding pressure on the artery until the bleeding stops. This usually takes fifteen to twenty minutes and may be assisted by the use of a closure device ("collagen plug") or vascular clamp if the physician feels that to be advisable. You will then be asked to remain at bedrest for a period of two to six hours to allow the leg to heal. Provided you feel well and your leg has healed you can expect to be discharged three to seven hours after the procedure is completed. If an angioplasty type procedure was performed you are generally observed overnight and discharged the following morning. On occasions the result of a diagnostic or therapeutic procedure dictates that the safest course of action is to remain in the hospital for open-heart surgery and should this occur it will be discussed with you by the physician performing the procedure usually after conferring with your cardiologist by telephone.

3. Risks

Cardiac catheterization and angioplasty are comparatively safe procedures when balanced against the natural history of the disease processes that they are designed to diagnose and treat. There are potential side effects and complications that can arise. The decision to recommend cardiac catheterization and or angioplasty has been carefully considered by your cardiologist after reviewing your symptoms and the results of prior testing. There are risks to your health of not treating your condition appropriately just like there are risks associated with the procedure itself. Your cardiologist has determined that the risk of the procedure is justified by the necessary information gained. Simply put your chances are better with the catheterization than without it because your doctor will be better able to treat you. Every patient's situation is unique and a frank discussion with your doctor is the best way to resolve any uncertainty. Side effects of invasive cardiac procedures (catheterization, angioplasty etc.) range from transient discomfort to life threatening complications. Some minor side effect can be expected in 1-2% of procedures and these include transient nausea and or vomiting due to the contrast dye, minor bleeding, back discomfort from lying flat, and pain or bruising at the access site. More severe complications occur less commonly (perhaps 1 in 200) including a large collection of blood outside the artery called a hematoma (which may even require a blood transfusion), kidney damage due to the contrast (usually is completely reversible after several days but on rare occasions can cause the need for dialysis) and damage to the adjoining nerve or artery to the point that a separate surgical procedure is required. These complication rates are estimates and can change depending on your health prior to the procedure. For example if your kidneys are already weak then it is more likely that the contrast could result in further compromise in kidney function or if your leg arteries are already severely diseased the likelihood of bleeding or the need for an operation is increased. Your physician is best able to estimate your risk since he has examined you, reviewed your blood tests and knows your medical conditions - naturally no person (physician or otherwise) can foresee the future with certainty. The most serious complications that can arise are fortunately extremely rare and again are most closely correlated with the status of your health and the condition affecting your heart. In less than 1 in 1000 cases stroke, loss of limb, heart attack, permanent nerve damage or death can occur. Again this is a general estimate which can increase with age, illness and the severity of your heart disease.

In summary, side effects and complications are uncommon but they do occur. Your cardiologist is best equipped to estimate your risk and explain the necessity of the procedure intended. The procedural physician has been trained in techniques to minimize the risks discussed above and to manage any side effects that arise. The catheterization team routinely performs the procedure you are undergoing and constantly examines its performance to ensure the highest quality of care possible.

4. After the Procedure:

After the procedure unless you are instructed otherwise you may return to normal activities except vigorous exercise for a period of five days (to allow complete healing of the artery). Returning to work depends on your condition and the results of the catheterization and you should consult your doctor if you have any questions. Common sense applies and usually return to work is two days for diagnostic catheterization and seven days for angioplasty type procedures but these are just averages and depend on what you do for a living, what procedure was done and the results of the procedure itself.

It is normal to have some discomfort at the site of the catheterization and it is not uncommon to have a small bruise. In some cases the bruise will track down the inside of the thigh particularly if significant blood thinners were used during the procedure. This bruising may appear to represent a large amount of blood but is akin to spilling a cup of liquid on a tabletop - a relatively small amount can spread out in the thin tissue plane and look much worse than it is. You may be able to feel a "walnut" at the site of the procedure and this represents the small plug or scar that has sealed the artery closed and which will soften in the next four to six weeks. There can be some redness of the skin particularly if you have a history of allergic reactions to tape. If you developed a "hematoma" (bleeding outside the artery) the swelling will soften and "spread out" (see above) and you will have a "black and blue" which will resolve over a couple of weeks. Whether it is discomfort or swelling the normal course of events is that it slowly improves and does NOT worsen.

It is abnormal to have increasing pain and swelling at the site of catheterization. Bleeding is abnormal unless it is just a trickle at the site of the skin nick. Symptoms of your heart condition may persist if this was a diagnostic catheterization (not an angioplasty type procedure) but they should not worsen. If you had an angioplasty your symptoms should improve and should not worsen. Some individuals who receive stents report a well-localized sharp pain usually felt with deep breaths - generally it develops right after the procedure and dissipates over the next day or so. As always it is best to report any new symptoms to your cardiologist.

5. Common Questions:

What about my medications after I go home? No change unless you were instructed otherwise. If you had a stent placed you will be given a medication called Plavix to be taken with aspirin. This is very important to insure adequate healing of the stented artery.

When do I see my doctor? Usually within two weeks if no immediate problems need to be addressed. If you do not receive a phone call the following day to check up on you please call the office.

What if I have a problem? Please call the office anytime. If it is after hours the physician covering the service will address your problem. Naturally it is best to ask routine (non-emergency) questions about your condition or the procedural results with your cardiologist rather than the covering physician who may not be privy to the specifics of your case.

Do I take my medications on the day of the procedure? Yes, except diabetes medications. Since you are not eating breakfast your diabetic medications are held that morning. If you are on insulin specific instructions will be given to you but in general the dose is cut in half and the regular (Humulin reg or Humulog) is held in the morning. It is better to have the glucose be a little too high than to be dangerously low.

What if I take Glucophage? This medication is held on the day of the procedure and is not to be resumed until 48 hours post the procedure usually after a blood test has verified that it is okay to do so.

Can the stent move? No. It is embedded in the artery and cannot move or be removed.

What about MRI if I got a stent? The stent is not ferro-magnetic and should not be affected. Nonetheless it is recommended that four to six weeks elapse before an elective MRI be performed.

Do I need to take antibiotics if I received a stent? Infection of a stent is extraordinarily rare, however, as with any implanted device prophylactic antibiotics have been recommended if you undergo a procedure known to cause bacterial seeding of the bloodstream in the first six weeks post stent placement. Usually this is a dental procedure and we do recommend antibiotics prior to a dental procedure done within six weeks of a stent procedure. Antibiotics are NOT required just for the placement of the stent itself.

Any special precautions if I received a stent? You will not set off airport metal detectors nor is there a concern with microwave ovens. It cannot be detected on regular chest x-rays. There are no allergic reactions or known late health consequences associated with stent placement.

Can the artery "renarrow" even after a stent is placed? Yes. Unfortunately the artery can "scar" through a stent over time (a process called "restenosis"). This can occur over three to nine months and result in return of symptoms. Fortunately it is relatively uncommon and restenosis rates are far lower than when regular balloon angioplasty was the only treatment available.