Stent

Coronary angioplasty is a procedure developed in the 1970’s used to open clogged heart arteries that cause chest pain or shortness of breath.  It revolutionized the practice of cardiology and was the first type of procedure known as a percutaneous coronary intervention.

An angioplasty is done by threading a catheter from an artery in the groin, or occasionally the wrist, up around the aorta and into a coronary artery with x-ray guidance. A coronary angiogram is performed, where contrast dye is injected though the catheter to outline what the inside of the coronary artery looks like and to see where a blockage is. Then, a very skinny and flexible wire is threaded through the catheter and past the area of blockage. Over this skinny wire is a tiny deflated balloon that is advanced to the area of blockage and inflated to help open the artery.

A new technique called coronary stenting was developed where a stent could be inserted into the area of blockage. The stent is inflated with a balloon to help prop open the artery, like scaffolding. The majority of patients requiring a PCI have stenting rather than just angioplasty depending of technical and clinical specifics of the situation.

Bare-metal stents did cut back down on restenosis rates but sometimes the inner lining of the artery that regrows over the stent regrows too much, causing restenosis.  It was discovered that if the stents were coated with certain types of medication, this regrowth could be reduced, so drug-eluting stents (DES) were developed.  Now, the majority of PCI’s are done with DES. It is recommended that patients stay on two anti-platelet blood thinners for at least one year after a DES and sometimes indefinitely thereafter.  Generally, all patients with coronary artery disease should be on at least one anti-platelet agent, usually aspirin.

The Pros and Cons of PCI (Do I need a stent?)

A primary PCI for someone coming into a hospital with a heart attack can help save lives and reduce the amount of permanent damage to heart muscle.  For someone whom is about to have a heart attack (unstable angina) there is still much debate among experts about which patients will benefit the most.

The short-term risk of PCI is generally quite low. However, most PCI’s have traditionally been done in patients who were not having a heart attack, but who have stable coronary artery disease. Since most patients having PCI end up with DES and the need for blood-thinners for an extended period of time, the question is whether PCI is appropriate for patients with stable coronary artery disease.

When all patients with stable coronary artery disease are considered, PCI generally has not been shown to prevent heart attacks or save lives. This is due to the fact that heart attacks can occur from a 40 or 50% blockage in a coronary artery, just as much as a 90% blockage.  And almost all patients with even just one area of severe coronary blockage have at least mild plaque throughout most of the other areas of their coronary arteries. This is why the foundation heart attack prevention involves treating all of the coronary arteries and all of the plaque, mild or severe. This is generally best accomplished by following a heart-healthy diet, participating in regular exercise as tolerated, and taking statins, aspirin and, when indicated, blood pressure medications. This is true whether someone gets a stent or not.

When angioplasty was first developed, it was hoped that it could replace coronary artery bypass surgery (CABG). The overall rates of CABG have dropped significantly but there are still patients, usually with many blockages in 2 or more coronary arteries. In those with diabetes and several blockages, CABG can still offer long-term advantages over PCI.

Recent trials have shown that many patients with stable coronary artery disease can safely be treated with medications with no more dangerous outcomes than proceeding with PCI as an initial strategy. PCI can still be an appropriate option if medications alone do not adequately treat symptoms. PCI can be more likely to reduce angina.

In patients with stable coronary artery disease, optimal medical therapy and heart-healthy lifestyle is essential. The need PCI or bypass surgery depends on looking at all details of the specific situation. This includes the skill and experience of interventional cardiologists and cardiac surgeons available, the individual preferences and concerns of the patient, and an objective assessment by the cardiologist of the risks and benefits.


Charles A. Shoultz, Jr., M.D., F.A.C.C.   •   Charles A. Shoultz, III, M.D., F.A.C.C.   •   Rodney A. Brown, M.D., F.A.C.C.
William R. Pitts, M.D., F.A.C.C.   •   Donald S. (Buck) Cross, M.D., F.A.C.C. • Andrew K. Day, M.D., F.A.C.C.
Sherwin F. Attai, M.D., F.A.C.C.   •   Shawn J. Skeen, M.D. F.A.C.C.   •   Harvey R. Chen, M.D. F.A.C.C.
Adam M. Falcone, M.D., F.A.C.C.   •   Brian C. Barnett, M.D., F.A.C.C.

Diplomates, American Board of Internal Medicine,
Cardiovascular Disease, Interventional Cardiology, Clinical Cardiac Electrophysiology