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Angioplasty with or without stenting is a nonsurgical procedure used to open clogged or narrow coronary arteries due to underlying atherosclerosis. The procedure involves introducing an inflatable balloon-tipped catheter through the skin in extremities and inflating the balloon once it traverses the stenosed arterial site. It pushes the atherosclerotic intraluminal plaque against the arterial wall and restores the luminal diameter. Thereby it normalizes the blood flow to the myocardium. Percutaneous coronary intervention (PCI) was formerly called angioplasty with stent and is the treatment of choice for unstable angina, myocardial infarction, and spontaneous coronary artery perforation. This activity reviews the indications, contraindications, and technique involved in performing angioplasty and highlights the role of the interprofessional team in the care of patients undergoing this procedure. Objectives: Contrast the indications for angioplasty without stent with the indications for percutaneous coronary intervention. Contrast the techniques for performing percutaneous coronary intervention via the femoral versus radial approaches. List the complications associated with angioplasty. Employ a structured, interprofessional team approach to provide effective care to and appropriate surveillance of patients undergoing angioplasty. Access free multiple choice questions on this topic.

Angioplasty with or without stenting is a nonsurgical procedure used to open clogged or narrow coronary arteries due to underlying atherosclerosis. The procedure involves introducing an inflatable balloon-tipped catheter through the skin in extremities and inflating the balloon once it traverses the stenosed arterial site. It presses the intraluminal plaque of atherosclerosis against the arterial wall and widens the luminal diameter. Thereby it normalizes the blood flow to the myocardium and achieves the goal of angioplasty or percutaneous coronary intervention (PCI) by alleviating the chest pain. The PCI concept was introduced 40 years ago with the introduction of "plain old balloon angioplasty" (POBA) without stenting. In the mid-1980s, POBA use was limited because of an early complication of vascular recoil property and restenosis after balloon deflation which led to the invention of bare metal stents (BMS). During the procedure, professionals use a tube-like metallic meshwork, and its scaffolding properties counteract vascular recoil property, thereby avoiding the early restenosis of POBA due to vascular recoil. However, long-term, in situ BMS, can induce wall stress, endothelial discontinuity, and permanent presence of the metallic foreign body in arteries leading to inflammation with fibrin deposition and promoting myofibroblast migration which gives rise to in-stent restenosis (IRS) due to a mechanism of neointimal hyperplasia.[1][2][3][4]

Angioplasty with or without stenting is a nonsurgical procedure used to open clogged or narrow coronary arteries due to underlying atherosclerosis. The procedure involves introducing an inflatable balloon-tipped catheter through the skin in extremities and inflating the balloon once it traverses the stenosed arterial site. It presses the intraluminal plaque of atherosclerosis against the arterial wall and widens the luminal diameter. Thereby it normalizes the blood flow to the myocardium and achieves the goal of angioplasty or percutaneous coronary intervention (PCI) by alleviating the chest pain. The PCI concept was introduced 40 years ago with the introduction of "plain old balloon angioplasty" (POBA) without stenting. In the mid-1980s, POBA use was limited because of an early complication of vascular recoil property and restenosis after balloon deflation which led to the invention of bare metal stents (BMS). During the procedure, professionals use a tube-like metallic meshwork, and its scaffolding properties counteract vascular recoil property, thereby avoiding the early restenosis of POBA due to vascular recoil. However, long-term, in situ BMS, can induce wall stress, endothelial discontinuity, and permanent presence of the metallic foreign body in arteries leading to inflammation with fibrin deposition and promoting myofibroblast migration which gives rise to in-stent restenosis (IRS) due to a mechanism of neointimal hyperplasia.[1][2][3][4] This issue led to the development of drug-eluting stents (DES). DES technology uses a coating of an antiproliferative drug on top of the metallic structure of stents with the benefit of causing less neointimal hyperplasia and stent restenosis as compared with BMS. Late stent thrombosis is also associated with DES due to impaired arterial healing with a lack if re-endothelialization and fibrin deposition due to underlying chronic inflammation more commonly in first-generation DES. Second-generation DES has an extra coating of biocompatible polymer with better endothelial healing. Cobalt-chromium everolimus-eluting stents (second-generation DES) is safer than paclitaxel-eluting stent (first-generation DES) and BMS due to better vascular healing and re-endothelialization of stent struts as evidenced in an animal model. Recent studies show that second-generation DES with biodegradable polymer coating proved to have more efficacy in reducing target-vessel revascularization (TVR), target-lesion revascularization (TLR), in-stent late loss (ISLL), and late-stent thrombosis as compared to BMS. Studies also showed the higher efficacy of DES in complex lesion as compared to BMS.

This issue led to the development of drug-eluting stents (DES). DES technology uses a coating of an antiproliferative drug on top of the metallic structure of stents with the benefit of causing less neointimal hyperplasia and stent restenosis as compared with BMS. Late stent thrombosis is also associated with DES due to impaired arterial healing with a lack if re-endothelialization and fibrin deposition due to underlying chronic inflammation more commonly in first-generation DES. Second-generation DES has an extra coating of biocompatible polymer with better endothelial healing. Cobalt-chromium everolimus-eluting stents (second-generation DES) is safer than paclitaxel-eluting stent (first-generation DES) and BMS due to better vascular healing and re-endothelialization of stent struts as evidenced in an animal model. Recent studies show that second-generation DES with biodegradable polymer coating proved to have more efficacy in reducing target-vessel revascularization (TVR), target-lesion revascularization (TLR), in-stent late loss (ISLL), and late-stent thrombosis as compared to BMS. Studies also showed the higher efficacy of DES in complex lesion as compared to BMS. The latest novel agent bioresorbable scaffolds system (BRS) maintains cyclic pulsatility with fewer chances of vascular remodeling and IRS due to the removal of metallic meshwork in stents platform which serves as triggering agent for late-onset complications such as IRS and stent thrombosis. However, BRS requires best implantation techniques and struts size. The limitation to BRS is struts thickness because in early post-procedural period restenosis is due to vascular recoil property which is counteracted by a metallic scaffold of BMS and DES. If struts size of BRS is reduced, vascular recoil cannot be antagonized adequately. Second-generation BRS has achieved this property somehow. After a time, BRS disappears entirely due to resorption which can be followed up with intravascular ultrasound (IVUS). IVUS and optical coherence tomography (OCT) can be used to install BRS appropriately. There is not much data available on the safety of BRS, but the idea of the metal-free stent that helped develop BRS is criticized because scaffold thrombosis has been reported. Recently, Brown et al. suggested that during BRS implantation, both pre-dilatation and post-dilatation with pressure over 20 ATM is mandatory for preventing acute vascular recoil, and better scaffold expansion, and lower rates of scaffold thrombosis which is best predicted by minimal luminal area on IVUS.

The latest novel agent bioresorbable scaffolds system (BRS) maintains cyclic pulsatility with fewer chances of vascular remodeling and IRS due to the removal of metallic meshwork in stents platform which serves as triggering agent for late-onset complications such as IRS and stent thrombosis. However, BRS requires best implantation techniques and struts size. The limitation to BRS is struts thickness because in early post-procedural period restenosis is due to vascular recoil property which is counteracted by a metallic scaffold of BMS and DES. If struts size of BRS is reduced, vascular recoil cannot be antagonized adequately. Second-generation BRS has achieved this property somehow. After a time, BRS disappears entirely due to resorption which can be followed up with intravascular ultrasound (IVUS). IVUS and optical coherence tomography (OCT) can be used to install BRS appropriately. There is not much data available on the safety of BRS, but the idea of the metal-free stent that helped develop BRS is criticized because scaffold thrombosis has been reported. Recently, Brown et al. suggested that during BRS implantation, both pre-dilatation and post-dilatation with pressure over 20 ATM is mandatory for preventing acute vascular recoil, and better scaffold expansion, and lower rates of scaffold thrombosis which is best predicted by minimal luminal area on IVUS. While treating small-sized coronaries arteries, DES has low efficacy with an increased incidence of IRS due to thicker stent’s struts size and luminal loss. To overcome this issue and treating IRS secondary to BMS and DES, drug-eluting balloons (DEB) served the purpose with higher efficacy. In a meta-analysis, a combination treatment of de novo coronary artery disease patients with DEB+BMS was superior to BMS alone with a significant reduction in major adverse cardiac events (MACE) and late lumen loss (LLL). However, DEB plus BMS combination was inferior to DES alone with higher rates of MACE, LLL or TLR. [5][6]

One rare but serious complication of angioplasty is iatrogenic coronary artery perforation (CAP) due to underlying complex lesion, occurring in 0.1% to 0.8 % of total cases undergoing angioplasty. CAP can be due to angioplasty guide wire perforation, balloon oversizing, and use of atherectomy devices. Management of CAP depends on the severity of the lesion, hemodynamic status, and Ellis class type of CAP. Class 1 is usually benign while class 3 is associated with higher chances of cardiac tamponade and need for emergent cardiac surgery. The mild CAP can be managed with an anticoagulation reversal (protamine sulfate in case of heparin use), prolonged balloon inflation, polytetrafluoroethylene-covered stents (CS), and trans-catheter embolization by autologous fat particles. CS use comes with the cost of stent thrombosis, and few cases of coronary arteriovenous fistula have also been reported due to CS failure. Complication of CAP is ST-segment elevation myocardial infarction, and early or delayed cardiac tamponade with or without hemodynamically instability which can require emergent pericardiocentesis.

One rare but serious complication of angioplasty is iatrogenic coronary artery perforation (CAP) due to underlying complex lesion, occurring in 0.1% to 0.8 % of total cases undergoing angioplasty. CAP can be due to angioplasty guide wire perforation, balloon oversizing, and use of atherectomy devices. Management of CAP depends on the severity of the lesion, hemodynamic status, and Ellis class type of CAP. Class 1 is usually benign while class 3 is associated with higher chances of cardiac tamponade and need for emergent cardiac surgery. The mild CAP can be managed with an anticoagulation reversal (protamine sulfate in case of heparin use), prolonged balloon inflation, polytetrafluoroethylene-covered stents (CS), and trans-catheter embolization by autologous fat particles. CS use comes with the cost of stent thrombosis, and few cases of coronary arteriovenous fistula have also been reported due to CS failure. Complication of CAP is ST-segment elevation myocardial infarction, and early or delayed cardiac tamponade with or without hemodynamically instability which can require emergent pericardiocentesis. In-stent restenosis (ISR) is defined as the reduction in vascular luminal diameter after percutaneous intervention (PCI). The underlying pathophysiology of ISR depends on the type of stent used during PCI. In case of POBA, it is acute in onset because of elastic recoil and vascular remodeling. BMS has the unique phenomenon of Neointimal Hyperplasia. DES has late stent thrombosis due to multiple underlying pathological causes such as decreased vascular re-endothelialization, polymer coating hypersensitivity, and increased fibrin deposition secondary to metal inducing chronic inflammation. In a meta-analysis, it was evident that patients with unstable angina or acute coronary syndrome who underwent PCI are more likely to develop ISR due to chronic inflammation which is predicted by higher C-reactive protein level (CRP) in these patients as compared to patients with stable angina who underwent PCI. Stent fracture (SF) is an infrequently reported adverse outcome of DES use during PCI which can either occur periprocedural or later on when drug elution has been completely done. SF has also been linked to the development of ISR and stent thrombosis. Irrespective of the type of intervention done during PCI, ISR can also be due to neoatherosclerosis. All of the causes mentioned above of ISR present with angina symptoms or acute coronary syndrome due to compromised blood flow to the myocardium and may require reintervention such as coronary artery bypass graft surgery or re-PCI. This reintervention is called target lesion revascularization. The incidence of ISR in the pre-stent era was 32% to 55% of all PCI done, 17% to 41% for BMS, and for second generation DES and DEB it dropped to less than 10% of total PCI done. Such a low rate is due to the evolution of stents under strong criticism and advanced technology.

Healthcare workers including the primary care provider and nurse practitioner who have patients with coronary artery disease should refer them to a cardiologist. One option for dealing with localized coronary artery lesions is angioplasty with stenting. The results of angioplasty with stenting rival those obtained with coronary artery bypass surgery for single and double vessel disease. In addition, angioplasty has considerable less morbidity compared to open heart surgery. Many trials have shown that angioplasty with stenting is a viable option for people of all ages, including the presence of diabetes. (Level II) However, all patients who receive a stent also need antiplatelet therapy and life long follow up as recurrence of stenosis is a common complication.