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Balloon Angioplasty | by heidi


 Balloon angioplasty, also known as percutaneous transluminal angioplasty (PTA), is a minimally invasive procedure done to widen narrowed or obstructed blood vessels. The procedure accesses a blood vessel via a catheter inserted through an incision in the skin. It is typically used to treat atherosclerosis caused by the buildup of plaque in a blood vessel but can also treat other conditions associated with narrowing or blockage of a blood vessel.



What Is Balloon Angioplasty?
Balloon angioplasty is an interventional technique in which a specially equipped catheter is inserted into a blood vessel and inflated to widen it and restore blood flow. Once inflated, an expandable mesh tube (called a stent) can be inserted to keep the vessel open.

Balloon angioplasty is typically a scheduled procedure performed under local anesthesia. Most procedures are performed on an outpatient basis, and do not require an overnight hospital stay.1

Balloon angioplasty is also sometimes used in emergency situations, such as during a heart attack, where it is performed under general anesthesia. On occasion, regional anesthesia, including nerve blocks, may be used if there is a vascular obstruction in the legs.2

Contraindications
Because balloon angioplasty is used to correct severely impaired blood flow, the benefits of treatment usually outweigh the risks. With that said, the procedure is not performed on vessels that are structurally unsound.3


In addition, balloon angioplasty cannot be performed on arteries or veins smaller than 1.5 millimeters (0.06 inches) in diameter.4

If there are multiple blockages or chronic total occlusion (in which a vessel is completely blocked for more than three months), bypass surgery is usually preferred over angioplasty.5


 What to Expect from Heart Bypass Surgery
Potential Risks
Although balloon angioplasty is regarded as minimally invasive, the procedure does involve risks, some of which may be serious. These include:

Restenosis: The narrowing of a vessel after the procedure is complete, resulting in retreatment
Accidental perforation: Often caused by an incorrectly sized catheter or the catheter guidewire
Blood clots: Sometimes may occur after the placement of a stent, particularly bare metal ones
Cardiac arrhythmia: Irregular heartbeat
Allergic reaction: Due to the use of contrast dyes
Kidney injury: Due to an adverse reaction to the contrast dye
Heart attack or stroke: Possible but uncommon6

Purpose of Balloon Angioplasty
Balloon angioplasty is primarily used to treat conditions associated with atherosclerosis (a.k.a. "hardening of the arteries") and/or vascular stenosis (the narrowing of a blood vessel).


Although the term is sometimes used interchangeably with coronary angioplasty (involving only the heart), balloon angioplasty has come to describe any intervention of its sort performed percutaneously (through a small puncture or incision) on any part of the body.


Among the conditions balloon angioplasty may be used for are:

Heart attack: Also known as myocardial infarction
Peripheral ischemia: Impaired blood flow in part of the body other than the heart or brain due to peripheral artery disease
Renal artery stenosis: The narrow of arteries in the kidneys due to chronic kidney disease or renal hypertension
Subclavian vein stenosis: The narrowing of the major vein that drains blood from the upper extremities
Unstable angina: Caused by impaired blood flow to the heart
Balloon angiography can be used as an alternative to minimally invasive procedures or more invasive ones, like a coronary artery bypass.

 Stents vs. Bypass Surgery: Which Is Better?
Pre-Operative Evaluation
Prior to ordering the procedure, the healthcare provider will schedule a series of pre-operative tests to establish the location and degree of vascular impairment. This typically involves a physical exam, imaging studies (such as CT or MRI angiography or a Doppler ultrasound), and specialized tests (like an ankle-brachial index used to check for peripheral artery disease).7

The pre-operative evaluation can also help the healthcare provider decide where to access a blood vessel (most often via the femoral artery or vein of the leg or the radial artery of the forearm).

If angioplasty is needed in an emergency, CT or MRI angiography will be performed in tandem with angioplasty as a single procedure.6

How to Prepare
Once preoperative evaluations have been completed, you will meet with an interventional cardiologist to review the results, walk you through the steps of the procedure, and discuss what to expect before and after treatment.

Location
Balloon angioplasty is performed in the cardiac catheterization unit of a hospital. The procedure room, often referred to as the "cath room," will be outfitted with the following equipment:

Endovascularlar balloon catheter: A flexible plastic tube with a tiny inflatable balloon at its tip
Fluoroscopy equipment: A real-time imaging system that uses X-rays and contrast dyes to transmit live images to a video monitor
Doppler ultrasound: A handheld device that images blood vessels with high-frequency sound waves
Electrocardiogram (ECG) machine: A device that monitors your heart's electrical activity
Pulse oximeter: A non-invasive device used to monitor blood oxygen saturation
There will also be a "crash cart" on hand in the event of a cardiac emergency.

What to Wear
You will need to change into a hospital gown for the procedure, so wear something comfortable that can be easily removed and put back on. Leave jewelry and valuables at home.

In preparation for fluoroscopy, you will be asked to remove metal objects such as your watch, dental appliances, hearing aids, eyeglasses, and piercings.

Food and Drink
You will need to stop eating at midnight on the night before your angioplasty to reduce the risk of pulmonary aspiration. On the morning of the procedure, you are allowed a few sips of water to take any medications your cardiologist approves of. Within four hours of the procedure, you should take nothing by mouth, including gum, breath mints, and ice chips.


 Why You Can't Eat or Drink Before Surgery
Medications
The cardiologist will advise you to stop taking certain medications that can promote bleeding, slow blood clotting, and impair wound healing. These include anticoagulants, which are stopped 48 hours before the procedure, and nonsteroidal anti-inflammatory drugs (NSAIDs), which are stopped four days beforehand.

Some diabetes medications may also need to be stopped several hours or days before the procedure due to the risk of hemodynamic instability.

Among the drugs your healthcare provider may ask you to stop are:

Advil (ibuprofen)
Aleve (naproxen)
Aspirin (salicylic acid)
Celebrex (celecoxib)
Coumadin (warfarin) 
Eliquis (apixaban)
Glucophage (metformin)
Insulin
Mobic (meloxicam)
Plavix (clopidogrel)
Xarelto (rivaroxaban)
Advise the cardiologist of any medications you take before undergoing balloon angiography. This includes over-the-counter sleep aids, vitamins, herbal remedies, and recreational drugs.

What to Bring
You will need to bring a driver's license or some other form of government photo ID to check in at the facility as well as your insurance card and an approved form of payment if coinsurance or copay costs are required upfront.

You will also need to bring a friend or family member to drive you home. Even if the procedure is performed under local anesthesia, you will usually be advised to not drive for a couple of days. Some procedures, particularly those involving the heart, may require you to avoid driving for a week.8

 How Soon Can I Drive After Anesthesia?
Pre-Op Lifestyle Changes
Smoking can impair recovery by causing the constriction of blood vessels, limiting the amount of oxygen and nutrients that reach the treated area. It also increases the risk of restenosis (in which the treated artery spontaneously narrows again).9

As a general rule, smoking should be stopped if you have heart disease or any vascular condition. This is especially true if treatments like balloon angioplasty are needed.

If you are unable to quit smoking, ask your healthcare provider for prescription smoking cessation aids, many of which may be fully covered under the Affordable Care Act.

 Quitting Smoking Can Improve Surgical Outcome
What to Expect on the Day of the Procedure
Upon arrival at the hospital, you will need to check in and fill out the necessary forms, including a medical history sheet and a consent form stating that you understand the aims and risks of the procedure.

Try to arrive no less than 30 minutes before the scheduled procedure, providing you ample time to fill out forms, sort out insurance issues, and sit quietly before the treatment begins.

Before the Procedure
After registration, you are taken to a preoperative area and provided a hospital gown to change into. A nurse will record your weight, height, and vital signs (temperature, blood pressure, heart rate) and take a sample of blood to check your blood chemistry and blood oxygen levels.

If the skin around the access site is hairy, the nurse will need to shave it. You can do so in the morning if you'd like, but the nurse will likely do it again to ensure the skin is perfectly smooth and clean.

Other pre-operative preparations include:

Electrocardiogram (ECG): Adhesive electrodes are attached to your chest and connected to the ECG machine.
Pulse oximetry: A pulse oximeter to loosely clamped to your finger to monitor blood oxygen levels.
Intravenous (IV) line: An IV catheter is inserted into a vein in your arm to deliver anesthesia, medications, and fluids as well as the contrast dye for fluoroscopic imaging.
An anesthesiologist typically will see you before the procedure to check for drug allergies or any adverse reaction to anesthesia you may have had in the past.

 Risks of General Anesthesia You Should Know
During the Procedure
Once the pre-operative preparations are complete, you are wheeled into the catheterization suite and positioned on the bed of the fluoroscopic imaging unit. Fluoroscopy helps guide the procedure by delivering real-time video images from within the blood vessel. A contrast agent, infused into the bloodstream through the IV line, ensures greater image clarity.

Depending on the aims of the procedure, you may be provided local anesthesia (which numbs the immediate area), regional anesthesia (which blocks pain signals in a specific area), or general anesthesia (which puts you fully to sleep). Monitored anesthesia care may also be used to induce "twilight sleep" for those undergoing local or regional anesthesia.

 What Is Monitored Anesthesia Care?
Thereafter, balloon angioplasty follows relatively standard steps:

A tiny incision is made into the skin to access the artery or vein.
A hollow tube, called an introducer sheath, is inserted into the blood vessel.
Under the guidance of the live video feed, a thin guidewire is fed through the introducer sheath to the site of the obstruction.
Following the path of the guidewire, the balloon catheter is gently eased into the center of the obstruction.
Once in place, the catheter is inflated. It is not uncommon to feel discomfort when this happens, although it usually disappears once the balloon is deflated.
In some cases, the cardiologist may repeat steps 4 and 5, using a drug-coated balloon catheter for the second pass. As the balloon expands, it coats the walls of the vessel with medications that reduce the risk of restenosis. After several minutes, the balloon is deflated.
If a stent is needed, another catheter mounted with a stent is fed along the guidewire into the newly opened passageway.
After the stent is positioned, it is fully expanded, locking itself into place and keeping the vessel open.
Additional X-ray images are taken to evaluate how fully the blood flow has been restored.
The catheter, guidewire, and introducer sheath are then removed, and the incision site is closed with sutures or adhesive surgical strips.10
Balloon angiography can take anywhere from one to two and a half hours to complete, depending on the location and severity of the obstruction.

 Is Stenting Always a Good Idea?
After the Procedure
Upon completion of the procedure, you are wheeled into the post-anesthesia care unit (PACU) and monitored by a nurse until you are fully awake. This can take 10 to 15 minutes for those provided intravenous sedation and up to 45 for those who have undergone general anesthesia.2

Once your vital signs are stable, you are wheeled to your room and given something to eat. Most people spend at least one night in the hospital for observation. Others need to stay longer.

It is not uncommon to experience headaches, grogginess, nausea, and fatigue after undergoing balloon angiography. These tend to resolve in a few hours, but let the nurse know if they persist. There may also be some bruising and occasionally a lump around the incision site, but these, too, will diminish if you give the limb a chance to rest.

Upon discharge, you are provided care instructions that you need to carefully follow.

Recovery
Upon your return home, you will likely be advised to avoid bathing for the first day and to generally take it easy, keep off your feet, and limit the amount of time you walk or stand. You should also avoid lifting anything heavier than 10 pounds as well as any unnecessary bending, squatting, or climbing stairs.

You can eat a regular diet but take extra care to drink plenty of fluids to keep yourself well dehydrated.

Healing
After 24 hours, you can remove any bandages the healthcare provider may have applied. You can shower but try not to soak the procedure site. Keep the wound dry and clean and follow the wound care instructions your healthcare provider gave you.

If there is any soreness, you can apply a cold compress to the procedure site for no longer than 15 minutes, moving it constantly to avoid frostbite. Although you need to avoid nonsteroidal painkillers, you ask your healthcare provider if Tylenol (acetaminophen) is OK.

With the proper amount of rest, most people can return to work and normal activities within a few days to a week.

When to Call 911
There can sometimes be a little bleeding around the incision site, but if the bleeding is steady or a fast-growing bump develops, you need to call 911 and follow the following instructions:

Lie down and place pressure on the procedure site for 20 minutes.
If the bleeding stops, stay still until help arrives.
If the bleeding does not stop, keep pressing until help arrives.
Long-Term Care
Whether a stent was inserted or not, you will be given a daily low-dose aspirin to reduce the risk of clotting. If a stent was placed, you will be prescribed a blood thinner like Coumadin (warfarin) or an antiplatelet drug like Plavix (clopidogrel) that you will need to take for a year or more.

You will also need to avoid vigorous exercise for around a month if a stent was placed to avoid displacement.

Your cardiologist will schedule follow-up appointments to see how you are healing and evaluate the treatment area with imaging studies and other lab tests.

Even if the results are satisfactory, your healthcare provider will want to see you regularly ton watch for restenosis, which affects roughly one in 10 people who have undergone balloon angioplasty, often within the first six months

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