Angioplasty refers to the re-opening or unclogging of a blood vessel that is significantly narrowed by plaque. It is most often used in patients with obstruction(s) in one or two coronary arteries. This is called called "single-vessel" or "double-vessel disease," respectively. Coronary artery bypass surgery remains the treatment of choice for severe multi-vessel disease, where three or more coronary arteries are significantly obstructed.
Angioplasty can involve:
Balloon dilation: This involves the insertion of a thin catheter attached to a tiny balloon into the artery that is blocked. When the catheter reaches the site of blockage, the balloon is inflated, flattening the plaque against the arterial wall and enlarging or re-opening the vessel. This technique is called percutaneous transluminal coronary angioplasty, "PTCA," or "balloon angioplasty."
Mechanical stripping of the inner lining of a blood vessel: This involves removal of plaque from the blood vessel with small surgical instruments.
Forceful injection of fibrinolytics: This involves injection of drugs that break down fibrin in blood clots, which may be used in conjunction with PTCA.
Placement of a stent: A stent, which is a slender tubular structure, is sometimes placed in the blood vessel wall during PTCA to hold open the blood vessel.
In people with a recent heart attack, an alternative to thrombolytic therapy is immediate coronary angiography followed by percutaneous angioplasty of the lesion responsible for the heart attack. This treatment is called "primary PTCA."
Primary PTCA is considered most strongly in individuals who:
Have evidence of an acute Q-wave heart attack
Can undergo PTCA within 12 hours of the first symptoms (or beyond 12 hours if pain persists)
Can have the procedure performed by a skilled and experienced operator in a setting where emergency surgery can be performed
Other individuals who may benefit from primary PTCA include those in whom thrombolytic therapy is not appropriate due to risks.
Coronary angiography and evaluation for possible PTCA is also useful at a later point for some individuals. These especially include those:
experiencing angina after the heart attack or instability of cardiovascular parameters (e.g., unstable blood pressure), or
scheduled for repair of certain mechanical from a heart attack
Coronary angiography and PTCA are not considered useful
within days of having received thrombolytic therapy
in survivors of a heart attack who are not thought to be appropriate candidates for coronary revascularization, the reestablishment of blood supply to a portion of heart muscle.
Coronary Artery Bypass Surgery
Coronary artery bypass surgery, also known also as "bypass surgery" and coronary artery bypass grafting (CABG), is an operation in which
a blood vessel is taken from elsewhere in the body (usually a vein from the leg or an artery from the chest)
the blood vessel is then used to create an alternate pathway of blood or bypass to the heart.
The procedure is extensive surgery that often requires opening the chest and temporarily stopping the heart. During this time, blood flow is maintained to body tissues by a heart-lung machine, which replicates the pumping action of the heart. (A newer procedure allows the heart to continue to beat, but this procedure is not as widely used.)
One end of the transplanted vessel called a graft is connected below the blockage in the coronary artery while the other end is attached to the aorta, the major artery that carries blood away from the heart and into the body. The bypass procedure is repeated for each blocked coronary artery. For example, "triple bypass" means that three grafts have been placed).
Bypass surgery is generally reserved for individuals
Whose coronary artery disease cannot be adequately treated by cardiac medications
significant obstruction of the three main coronary arteries
depressed pumping action or blockage of the left anterior descending artery
They have typically not responded to intensive medical treatment for angina or have just suffered an acute heart attack.
Bypass surgery is performed in people
With an evolving heart attack when pain and ECG findings are unstable
Who failed angioplasty (They still have persisting pain or continue to be unstable after angioplasty)
Who are undergoing repair of mechanical complications such as a tear in the wall dividing the ventricles (ventricular septal defect) or heart valve insufficiency ("leaky" heart valves)
Other individuals who may benefit from CABG after a heart attack include those who are suffering from cardiogenic shock or who remain unstable after PTCA.
While bypass surgery can limit damage in people with an acute heart attack, it does not cure the underlying coronary artery disease. Many still require medications after CABG. Lifestyle modification and cardiac rehabilitation is recommended.
Recovery time following CABG is influenced by a person's age, overall health, and cardiac function.