If you have coronary heart disease it means that the inside
walls of the main arteries to your heart (the coronary arteries)
have become narrowed by a build-up of fatty material called
atheroma or atheromatous plaque. Coronary heart disease can
cause angina and heart attacks.
There are several different types of 'revascularisation treatment'
which can help to correct this. 'Revascularisation' means
making the blood vessels wider or replacing blocked arteries
with grafts. Revascularisation treatments include:
Coronary
angioplasty
Angioplasty
with stenting
Coronary
bypass surgery, and
Other forms
of heart surgery, such as transmyocardial laser
revascularisation
and percutaneous laser revascularisation.
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Who needs to have coronary angioplasty
or bypass surgery?
Many people live with 'stable angina'. This is when the symptoms
of angina do not vary much and can be controlled using medicines.
Most people with stable angina-if they take medicines for
their heart and make certain lifestyle changes-live a normal
or nearly normal life for many years. For others, a cardiologist
(a doctor specialising in the heart) or a heart surgeon may
advise angioplasty or heart surgery. This can control the
angina symptoms more effectively and, for some people, can
prolong life.
Before the doctors decide what treatment to advise they will
ask you to have a cardiac catheterisation (also called a coronary
angiogram). This test shows where your arteries are narrowed
and how narrow they are. Sometimes, if the person has agreed
to it beforehand, the doctors will do an angioplasty at the
same time as the catheterisation test.
Coronary angioplasty and heart surgery are usually planned
in advance, but in a few cases they may be carried out as
an emergency treatment.
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Coronary Angioplasty
Also called PCI (percutaneous coronary revascularisation),
balloon angioplasty or balloon dilatation or PTCA (percutaneous
transluminal coronary angioplasty).
Coronary angioplasty is a technique for treating coronary
artery disease. It was first used in 1977 and has developed
rapidly since then. Over 30,000 angioplasties are now done
each year in the UK.
Coronary angioplasty 'squashes' the atheroma (fatty tissue)
in the narrowed artery, allowing the blood to flow more easily.
Before you have the angioplasty you will be given a local
anaesthetic. A catheter (a fine, hollow tube) with a small
inflatable balloon at its tip is passed into an artery in
either your groin or your arm.
The operator then uses X-ray screening to direct the catheter
to a coronary artery until its tip reaches the narrowed or
blocked section. The balloon is then gently inflated so that
it squashes the fatty tissue responsible for the narrowing.
As a result, this widens the artery. The catheter contains
a 'stent' which is a short tube of stainless-steel mesh. As
the balloon is inflated, the stent expands so that it holds
open the narrowed blood vessel. The balloon is then let down
and removed, leaving the stent in place.
In the past, angioplasty was done without using stents, but
stenting is now routine, unless the artery is not large enough
to accept one.
Stent technology has improved significantly over the last
ten years allowing many different artery narrowings to be
treated. Recent advances have lead t the development of drug
coated stents that virtually abolish the potential for narrowings
to recur. At present these are in limited supply and targeted
towards patients who would benefit maximally. Although it
sounds simple, angioplasty/stenting is technically very difficult
to do. It is very similar to the cardiac catherisation test.
However, it can take much longer to get the balloon catheter
into exactly the right position. While the balloon is being
inflated, you will probably get angina symptoms, but the pain
eases very quickly when the balloon is let down again.
If you are having angioplasty with stenting, you will be given
'anti-platelet drugs' at round about the same time of the
angioplasty. This will help reduce the risk of clots forming
around the new stent. (Platelets are tiny particles in the
blood which are the first step in forming clots that may block
the stent. The anti-platelet drugs combat this effect).
Coronary angioplasty cannot be used for all people with angina.
Before you are accepted for coronary angioplasty, you will
need to have a cardiac catheterisation test (angiogram). At
the moment, over half of the people tested are suitable for
angioplasty. In some patients, either there are too many narrowings
in the arteries, or the narrowings are too tight or too long
and cannot be put right with current technology.
Angioplasty can also be used if you have had coronary bypass
surgery but your graft has become narrowed or you develop
new narrowings after a bypass operation.
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How Successful is Coronary Angioplasty?
The success rates of angioplasty procedures in excess of 95%.
A small number of patients may have complications. Sometimes
the treatment completely blocks off the narrowed artery. If
this happens and the doctor thinks this will do serious damage
to the heart, he or she may ask a surgeon to do an immediate
bypass graft operation. So, if you are having angioplasty,
you need to understand that you may have to have urgent heart
bypass surgery and you must be prepared for this. Urgent surgery
is needed in no more than 1 in every 200 cases, and the results
of this type of surgery are good.
After angioplasty, the arteries may get narrow again in time.
Using stents has greatly improved the success rate of angioplasty.
After angioplasty with stents, only 10% of artery narrowings
need repeat angioplasty (for clinical restenosis). Usually
this occurs in the first six months. Before stents were used,
1 in 3 arteries got narrow again within 4 to 6 months. Drug
coated stents reduce this further to around 1%.
Stents can also help to reduce the small risk of the coronary
artery becoming completely blocked, which sometimes happens
when an angioplasty is carried out.
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Right coronary Artery blockage
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Right coronary Artery after Angioplasty/Stenting
Other methods of angioplasty, such as rotablation and direct
atherectomy and laser angioplasty, are used occasionally to
physically remove the build up of plaque. Researchers are still
trying to find out whether these new methods have definite advantages
over ordinary angioplasty or angioplasty with stenting. In most
cases balloon angioplasty with or without stenting is the treatment
most doctors choose.
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Atherectomy devices
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Top image:
Top directional atherectomy device
Bottom Left image: bottom rotational atherectomy (rotatablator
device)
Bottom Right image: Thrombectomy device |
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After the Angioplasty
After the angioplasty, a nurse will check your blood pressure
and heart rate regularly for four to eight hours. The nurse
will also check the place where the catheter was inserted
(the 'puncture site'), and the pulses in your feet or arm.
If the puncture site was in your groin, you will have to stay
in bed lying on your back for a few hours after the operation.
If the puncture site was in your arm, you may be able to sit
up.
'Collagen plugs' are often used now to close the hole in the
artery so that the sheath can be removed immediately after
the angioplasty.
If you get chest pain after the angioplasty, tell the nurse
or doctor. You can expect to have some mild pain, but if the
pain is severe you may need to have more tests.
Most people can go home the day after the angioplasty. Arrange
for someone to take you home rather than driving yourself.
Before you leave the hospital the doctor or nurse will tell
you what you can and cannot do when you get home. They will
tell you about what drugs you need to take and about your
follow-up appointment. They will also offer advice on how
you can improve your diet and lifestyle once you get home.
For the first few days after you get home, check your puncture
site. You can expect to have some bruising, but if there is
any redness or swelling, contact your GP (family doctor) or
the hospital doctor.
It is best to avoid any demanding activities, like heavy lifting,
for at least a week.
If you have an ordinary driving license, you should not drive
in the first week after having your angioplasty.
If you have an LGV (large goods vehicle) or PCV (passenger-carrying
vehicle) license, you should not drive for at least 6 weeks
after angioplasty and you will need to have further tests
before you can drive an LGV or PCV again.
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Coronary Bypass Surgery
The aim of coronary bypass surgery is to bypass (get around)
the narrowed sections of coronary arteries. The heart surgeon
does this by grafting a blood vessel between the aorta (the
main artery leaving the heart) and a point in the coronary
artery beyond the narrowed or blocked area.
Doctors can carry out a bypass graft for each of the main
coronary arteries affected. Most people have three, four or
sometimes more grafts as the surgeon tries to do as thorough
a job as possible to make sure that the operation lasts. In
most cases at least one of the blood vessels used for the
grafts is made using an artery from inside the chest called
the internal mammary artery. (The left and right internal
mammary arteries supply blood to the breastbones but this
area does also have another sources of blood supply). The
internal mammary artery is less likely to narrow over time
than a vein graft. Blood vessels from other parts of the body
are used for the other grafts-usually from the leg or an artery
in the arm, or both.
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Typical bypass with internal
mammary artery and vein grafts
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In most heart operations, the surgeon reaches the heart by
making an incision (cut) down the middle of the breastbone.
Just occasionally they may use a different approach.
Usually the surgeon uses a heart-lung machine to circulate
blood around the body while operating on the heart. In some
cases the surgeon may be able to operate on the coronary arteries
while the heart is beating, without needing to use a heart-lung
machine. But there is always a machine available in the operating
theatre in case it is needed.
While the heart-lung machine is doing the work of your heart
and lungs, the surgeon can temporarily stop your heart with
potassium, or stop its rhythmical beating electrically. The
heart starts to beat again as soon as the blood supply is
restored.
After the operation, you will have a scar down the length
of your breastbone. You are bound to feel discomfort in your
chest immediately after surgery, but this usually eases off
over the next few weeks. If a vein has been removed from your
leg, you will also have some discomfort and swelling there.
Most patients are sitting out of bed or two after the operation
and return home in about a week.
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How successful is the operation?
Between 6 and 9 in every ten patients who have a bypass operation
get immediate relief from angina, lasting for at least 5 years.
Most of the others find that the bypass improves their angina.
However, the bypass operation does not affect the cause of
atheroma. So your angina may return if the atheroma builds
up inside the graft. This is more likely to happen if you
carry on smoking or don't control your blood pressure or cholesterol.
Narrowing of the graft happens in about 1 in every 20 patients
each year. If the angina does come back, you will probably
need to have another coronary angiogram and, depending on
the results, you may be advised to take medicines, or have
an angioplasty (see page 9) or another heart operation.
Over 28,000 patients have coronary artery bypass surgery in
the UK each year. The risk of dying within a month of a first
operation is low - about 2 or 3 in every 100 patients. This
is the same level of risk as for a major operation on the
abdomen.
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Keyhole Coronary Surgery
Instead of using a full incision (cut through the breastbone,
some heart operation scan be carried out through smaller and
more limited 'keyhole' incisions. Keyhole surgery is only
used in special circumstances. It is not suitable for all
patients because the surgeon usually needs to access to get
to all sides of the heart to do the 3, 4 or more grafts that
are needed.
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Port Access Surgery
This involves making a series of small incisions (cuts) in
the chest. The surgeon then operates using a viewing telescope
and special catheters. A specially adapted heart-lung machine
takes over the work of the heart and lungs while the surgeon
carries out the bypass surgery.
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Beating Heart Surgery
In some centre's heart bypass operations are carried out while
the heart is still beating, with doctors getting access to
the heart through a full chest incisions (cut). This means
that the doctors do not need to use a heart-lung bypass machine.
The results of long-term trials of this procedure have so
far been good but more research is needed.
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Coronary Angioplasty or Bypass
Surgery?
Your coronary angiogram may show that nothing needs to be
done. However, if it shows that your angina is caused by one
or more blocks or narrowings in the coronary arteries, your
specialist will decide whether:
* Your coronary arteries can be improved by an angioplasty,
or
* An operation is the best solution, or
* Either treatment can be used in your case.
If you are suitable for either angioplasty or bypass surgery,
you can be offered a choice. There are advantages and disadvantages
to both procedures, and in the end it is your decision. You
can see what the main differences are in the box below. Angioplasty
avoids the need for a major operation. However, people who
have angioplasty are more likely to get angina again than
people who have bypass surgery, so they may be more likely
to need further treatment or heart surgery later.
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Angioplasty or Bypass Surgery?
The information given below about the risks involved in angioplasty
with stenting and in bypass surgery is for planned procedures
to treat angina. The risks are higher if the procedures are
carried out to save a life soon after a heart attack, or if
they are done urgently in patients whose angina is very unstable.
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Angioplasty
with Stenting |
Bypass
Surgery |
| What
sort of anaesthetic is used? |
Local anaesthetic |
General anaesthetic |
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How long do you need to stay in hospital after
the operation? |
1 to 2 days |
6 to 10 days |
| How
soon can you return to work? |
5 to 7 days |
2 to 3 months |
| How
many people need to have angioplasty or bypass surgery
again? |
3
in every 100 people within 6 months.
(Longer-term figures are not yet available, as angioplasty
with stenting is a relatively new procedure). |
Between
1 and 2 in every 100 people within 6 months.
Between 5 and 10 in every 100 people within 5 years. |
| How
many people die within 30 days of the operation? |
5 in every 1,000 |
About 20 in every
1,000 |
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WHAT HAPPENS AFTER BYPASS SURGERY
Convalescence
After bypass surgery, many people find that they have a mixture
of emotions-happy to be home again, but at the same time feeling
anxious and perhaps afraid. So we recommend that somebody
is with you at home for the first week or two. If you live
alone, arrangements could be made for extra care during the
early days. For example, it may be possible to arrange for
a district nurse to visit you from time to time. Your hospital
or GP might be able to arrange this.
As soon as you get home, you or your family should let your
GP know that your are out of hospital, so that he or she can
give you the care you need.
It takes most people about 2-3 months to recover fully after
the operation. Obviously, the recovery time varies greatly
depending on how severe your heart disease is and how old
you are. For the first 3-6 months you are likely to feel very
tired, especially at the end of the day. This should gradually
improve over 12-18 months.
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Pain
The breastbone that was split for the operation takes many
weeks to heal. During this time, you may often feel pain in
your muscles especially in the centre of your chest, and in
your neck, back and arms. This is part of the normal healing
process and you don't need to worry about it.
If a vein was removed from your leg for the bypass graft,
your leg may also feel uncomfortable. Many people feel numbness
or pins and needles around the scar on their legs. This is
quite usual and you don't need to worry about it. You may
also have some swelling in your leg. It will help if you wear
an elastic support stocking and keep your leg raised when
sitting down for the first few weeks at home.
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Emotional Reactions
Quite a few people feel depressed a few days after the operation.
This is a natural reaction to the considerable stress and
upheaval of major heart surgery. You may also be understandably
anxious, and worry that you are not making good progress.
If you feel anxious or depressed, contact your GP who may
be able to help or reassure you.
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Memory Loss
Some patients (between 1 and 5 in every 100) lose some memory
after bypass surgery. This is usually temporary and improves
in the 6 months after the surgery.
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Cardiac Rehabilitation Programme
All hospitals should invite patients to a cardiac rehabilitation
programme, usually starting about 4-6 weeks after heart surgery.
The programme includes exercise sessions and advice on lifestyle
including healthy eating and relaxation techniques. It usually
involves going once or twice a week for about 6-8 weeks. Or,
you may be able to do a rehabilitation programme at home.
The aim of cardiac rehabilitation is to get you back to as
full a life as possible. Once the programme is over you may
want to join a heart support group. This will give you and
your partner or family the chance to meet and talk to people
who have gone through similar experiences.
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Sex
Most doctors suggest waiting about 4 weeks after the operation
before having sex again. You will need to find a position
which is comfortable for you. Remember - do not put pressure
on your chest wound or restrict you breathing.
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How Soon Can I go back to Work?
Many people return to work after bypass surgery. How soon
you can return depends on the kind of work you do. People
who do non-manual work can usually go back to work any time
from around 2 months after the operation. If you have a heavy,
manual job you may not be able to return to work for at least
3 months after surgery. Your body will need this time for
the muscles, bones and joints of the chest wall to heal completely.
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Driving
If you have a regular driving license, you don't need to contact
the DVLA (Driver and Vehicle Licensing Agency) after bypass
surgery. However, if you have had bypass surgery, you should
not drive for at least 4 weeks after the operation.
If you have an LGV (large goods vehicle) or PCV (passenger-carrying
vehicle) license, you should not drive for at least 6 weeks
after bypass surgery or angioplasty. You must let the DVLA
know about your operation. Before you can get your license
back, you will need to have a successful exercise test result.
If you have had bypass surgery, you should contact your care
insurance company to let them know. If you have any problem
with continuing your insurance policy, the British Heart Foundation
can send you a list of insurance companies who are 'sympathetic'
to heart patients.
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