Angioplasty

Angioplasty is a medical procedure based on the principle of “internal expansion,” performed to treat narrowings in the arteries of the heart or other parts of the body. When coronary arteries supplying the heart tend to become blocked, a special balloon or similar device is advanced through the vessel to the narrowed segment and inflated to widen it. This restores blood flow toward normal levels, improves nourishment of the heart muscle, and relieves or eliminates symptoms such as chest pain (angina). During the procedure, a support structure called a “stent” is usually placed to help prevent the vessel from narrowing again. Because angioplasty is performed with only a catheter (a thin plastic tube) and no open surgical incision, it is considered a “minimally invasive” technique. This increases patient comfort and shortens recovery time.

What Is Angioplasty and Why Is It Performed?

Angioplasty is a treatment method aimed at improving blood flow by widening narrowed or blocked areas in the vessels. Blockages in the coronary arteries that supply the heart can prevent oxygenation of the heart muscle, leading to serious consequences ranging from chest pain (angina) to heart attack (myocardial infarction). In other words, angioplasty is like “expanding a clogged water pipe from the inside.” Just as a clogged pipe at home causes pressure to drop and water flow to stop, narrowing of a vessel in the heart reduces blood flow to the heart.

Of course, not only heart vessels but also peripheral vessels—such as those in the leg—can be opened by angioplasty. However, its most common and well-known use is in treating coronary arteries, often referred to specifically as “coronary angioplasty.” The core idea is to reach the narrowed area with a thin catheter and expand it with a balloon. If needed, a stent is then placed in the expanded segment. A stent can be thought of like a spring placed inside a pipe: when the balloon inflates, the spring expands and holds the vessel at a fixed diameter.

Why Choose Angioplasty?

• Less invasive intervention: Performed through smaller incisions compared to open-heart surgery; often only a needle entry at the wrist or groin is needed.
• Shorter recovery time: Patients are typically discharged the same day or the next day and can return to work and daily activities quickly.
• Rapid intervention in acute cases: When performed in the first hours of a heart attack, it can minimize damage to the heart muscle.
• Less pain and fewer complications: Because it usually does not require general anesthesia and involves minimal tissue incision, pain and complication risks are lower than with open surgery.

Step by Step: How Is Coronary Angioplasty Performed?

Coronary angioplasty is usually performed under local anesthesia and sometimes light sedation, offering significant comfort to the patient. When we examine the steps of this procedure in detail, we see it is a highly planned and disciplined process:

Vessel Access

• The first step is choosing the artery for catheter entry, most often the radial artery in the wrist or the femoral artery in the groin. The choice depends on the patient’s vessel anatomy and the physician’s experience. The access site is numbed with local anesthesia, and a small incision or puncture is made. A small sheath is inserted to facilitate repeated entry and exit into the artery.

Advancing the Guidewire and Catheter

• A thin, flexible guidewire is advanced through the vessel toward the heart. Then the catheter—a thin tube—is threaded over the guidewire. Under fluoroscopy (live X‑ray imaging), the catheter tip is guided step by step into the coronary arteries. This stage is like “reading a map,” with the physician watching the catheter’s path on the X‑ray monitor.

Contrast Injection and Imaging (Coronary Angiography)

• Once the catheter reaches the coronary artery entrance, contrast dye is injected to visualize the vessel interior. The images reveal the exact location of any narrowing or blockage, allowing the physician to pinpoint the target area with millimeter precision. This “exploration” phase is called coronary angiography.

Balloon Catheter Placement

• A special catheter with a small balloon at its tip is advanced to the identified narrowing. The balloon is then inflated, pressing plaques and other debris against the vessel wall to enlarge the vessel lumen.

Stent Placement (If Needed)

• In many cases, a stent mounted on the balloon is deployed immediately after balloon dilation. When the balloon inflates, the stent expands and forms a scaffold to keep the vessel open. The balloon is then deflated and removed, leaving the stent in place.

Hemostasis and Dressing

• After the procedure, the catheter and guidewire are withdrawn. The access site (wrist or groin) is closed using a pressure device, sutures, or a compression pad. Once bleeding is controlled, a small dressing is applied.

Observation and Discharge

• The patient is monitored in the hospital for several hours or overnight to watch for bleeding, heart rhythm issues, and other potential complications. If all is well, the patient is typically discharged promptly.

What Are the Different Types of Angioplasty?

Although angioplasty fundamentally involves opening a blocked or narrowed vessel, various techniques and devices can be used depending on factors such as vessel anatomy, location and length of the blockage, and plaque characteristics (calcified vs. soft). The most common methods include:

Balloon Angioplasty (Percutaneous Transluminal Angioplasty – PTA)

• This traditional method, also called “plain balloon angioplasty,” involves inflating a balloon-tipped catheter at the blockage site. It is widely used in peripheral arteries (e.g., legs, kidneys). In some cases, balloon dilation alone suffices, but restenosis risk is higher without a stent, so stenting is more common.

Balloon Angioplasty with Stent Placement

• The most familiar form of coronary angioplasty, combining balloon dilation with stent deployment to maintain vessel patency. The stent both presses plaques against the vessel wall and provides structural support to reduce restenosis risk.

Drug‑Eluting Stents (DES)

• These stents are coated with medications that inhibit cellular proliferation on the vessel wall, significantly lowering restenosis rates. The drug release occurs over time, and the stent remains permanently in place. DES are preferred for high‑risk patients, such as those with diabetes or previous restenosis.

Atherectomy Techniques

• Instead of compressing plaque, atherectomy physically removes or shaves it. Techniques include rotational atherectomy (rotablator) and orbital atherectomy, used for heavily calcified plaques that resist balloon or stent expansion.

Laser Angioplasty

• Using laser energy to vaporize plaque tissue, this method can be combined with balloon or atherectomy for heavily calcified or fibrotic lesions. It is less common but effective in selected cases.

Drug‑Coated Balloons

• Balloons coated with antiproliferative drugs deliver medication to the vessel wall during inflation, reducing restenosis without leaving a permanent implant. Increasingly used in peripheral artery disease or where stenting is unsuitable.

Bioresorbable Scaffolds

• Made from biodegradable polymers, these scaffolds support the vessel temporarily (usually 2–3 years) before dissolving, aiming to restore the vessel’s natural state. This technology is still under development and not yet standard for complex lesions.

How Do Stents Work in Angioplasty and What Types Are There?

When discussing angioplasty, balloons and stents often go hand in hand. Balloon dilation opens the narrowed segment, but elastic recoil of the vessel can cause it to narrow again when the balloon is deflated. A stent—a fine metal mesh—acts as an internal scaffold to maintain the vessel’s expanded diameter.

Basic Stent Types

• Bare‑Metal Stent (BMS): The first stent type, made solely of metal with no drug coating. Although largely supplanted by drug‑eluting stents due to higher restenosis rates, BMS may still be used in specific situations or large‑diameter vessels.
• Drug‑Eluting Stent (DES): Coated with medication to inhibit cell proliferation on the vessel wall, significantly reducing restenosis. Preferred for high‑risk groups such as diabetics or patients with prior restenosis.

Next‑Generation and Specialized Stents

• Bioresorbable Scaffolds: Made from biodegradable polymers, these scaffolds support the vessel temporarily before dissolving, aiming to restore natural vessel function. Long‑term outcomes are still under study.
• Polymer‑Free or Thin‑Polymer‑Coated Stents: Utilize refined drug‑coating techniques for controlled, balanced drug release, aiming to reduce stent thrombosis and excessive tissue growth.

What Are the Risks and Complications of Angioplasty?

Like all medical interventions, angioplasty carries certain risks and potential complications. Advances in technique, more experienced teams, and safer materials have significantly reduced these risks, but patients should still be aware of the main concerns:

Bleeding and Hematoma

• Access‑Site Bleeding: After catheter removal from the wrist (radial artery) or groin (femoral artery), bleeding or hematoma may occur at the entry site.
• Risk Factors: Advanced age, use of anticoagulant medications, and high blood pressure increase bleeding risk.

Vessel Injury or Dissection

• Rarely, the vessel wall may tear or become damaged during catheter advancement, sometimes requiring additional intervention or emergency surgery. Heavily calcified vessels pose higher risk.

Stent Thrombosis and Restenosis

• Stent Thrombosis: Blood clots may form at the stent site, especially within the first days or weeks, increasing heart attack risk. Dual antiplatelet therapy significantly lowers this risk.
• Restenosis: Months after angioplasty, the stented segment or its edges may narrow again. Drug‑eluting stents have greatly reduced—but not eliminated—this risk.

Heart Attack or Arrhythmia

• Plaque debris or clot formation during the procedure can trigger a heart attack. Balloon inflation may temporarily cut off blood flow to a heart region, causing arrhythmias. These complications are rare and usually managed promptly.

Allergic Reactions

• Allergy to contrast dye or stent metals (nickel, chromium) can cause skin rash, itching, breathing difficulty, or anaphylaxis. The medical team screens for allergies and takes preventive measures when needed.

Kidney Dysfunction

• Contrast dye can stress the kidneys, especially in patients with preexisting kidney disease or diabetes. Monitoring renal function, ensuring adequate hydration, and administering protective medications help reduce this risk.

Rare Serious Complications

• Vessel Rupture: Full‑thickness tear of the vessel wall, potentially life‑threatening.
• Stroke: Dislodged clot may travel to the brain, causing stroke, though this is uncommon.
• Death: Extremely rare, more likely in older patients with multiple vessel disease or severe comorbidities.

What Is the Typical Recovery Time after Angioplasty?

Recovery after angioplasty is generally much shorter compared to surgical methods. Individual factors such as overall health, age, comorbidities, and technique used will affect recovery time, but in general:

First Hours and Hospital Stay

• Access‑Site Monitoring: The wrist or groin entry site is checked for bleeding, swelling, or pain, with pressure applied for several hours.
• Mobilization: If accessed via the wrist, the patient may walk lightly the same day after a few hours of rest. With groin access, bed rest on the back for 4–6 hours is usually recommended to reduce bleeding risk.
• Discharge: If no complications arise, most patients go home within 24 hours. Some centers even perform same‑day angioplasty.

First Days at Home

• Rest and Activity: Light rest for a few days, avoiding heavy lifting or prolonged standing. Mild wrist soreness or bruising is normal.
• Medications: Dual antiplatelet therapy (e.g., aspirin + clopidogrel), cholesterol‑lowering drugs (statins), and blood pressure medications are prescribed. Strict adherence is essential.

After One Week

• Physical activity can be gradually increased. Light walking or doctor‑recommended exercises are encouraged.
• Desk workers may return to work within 1–2 weeks; heavy laborers may need more time.

After One Month and Beyond

• In emergency cases (heart attack), full cardiac recovery may take several weeks, with return to strenuous exercise in 4–6 weeks.
• Follow‑up angiography or stress tests evaluate stent status. Any new chest pain or shortness of breath warrants immediate medical consultation.

Long‑Term Lifestyle

• Angioplasty is not a magic wand. Maintaining healthy diet, regular exercise, and smoking cessation is vital to reduce future blockages.
• Uncontrolled cholesterol, blood pressure, or diabetes can lead to stent restenosis or new blockages in other vessels.

Prof. Dr. Özgür KILIÇKESMEZ

Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.