SHRI G.S.

INSTITUTE OF TECHNOLOGY & SCIENCE

(AN AUTONOMOUS INSTITUTION ESTABLISHED IN 1952)

DEPARTMENT OF BIO MEDICAL ENGINEERING REPORT ENDOSCOPY AND ANGIOPLASTY

SUBMITTED TO:SUBMITTED BY:Mrs. VIBHA BHATNAGAR AB~39001 ADITYA GUPTA

AB~39004

ASHISH ADWANI

Foreign Body Extraction

General
A variety of foreign bodies may accidentally or intentionally enter the gastrointestinal (GI) tract. In about 90% of cases, however, they spontaneously pass out through the GI tract. The remaining 10% comprise sharp, pointed, or bulky objects, which can cause local trauma or chemical damage to the mucosa. Nearly all such foreign bodies can be extracted with a flexible endoscope.

Indications
An emergency indication for endoscopic extraction is an impacted foreign object. Acute obstruction of the esophageal lumen can cause aspiration pneumonitis or pressure on the esophageal wall resulting in perforation and mediastinitis. Foreign objects can become impacted in the esophagus at the three physiologic levels of narrowing: the cricopharyngeal sphincter, aortic arch, and diaphragmatic hiatus. Objects that reach the stomach and are likely to pose a risk of mechanical or toxic

injury should also be removed without delay. In addition, objects that remain in the stomach for more than 72 hours should undergo early endoscopic extraction since their spontaneous passage is unlikely. A bezoar requires debulking by endoscopic fragmentation to facilitate its removal.

Prerequisites
Prior to endoscopic extraction of a foreign body, information regarding the type, form, and size of the foreign body is required to plan the strategy of removal and to select the instruments to be used. A plain radiograph of the upper GI tract may not always adequately localize the foreign body, and therefore a contrast study may be necessary. If a perforation is suspected, a water-soluble contrast agent like Gastrografin is preferred. The colon may also require evaluation with a contrast enema study. If an esophageal foreign body is suspected, then a plain radiograph of the chest should also include the neck as it is not unusual for foreign bodies to impact at the cricopharyngeal sphincter. Children and uncooperative adults often require general endotracheal anesthesia so that the procedure can be carried out safely and successfully.

Figs. 16) Fig. 1a, b Extraction of a coin from the esophagus. a In children, a coin often impacts at the level of the cricopharyngeal sphincter.

b A coin with an elevated edge is easy to grasp and extract with the rat-tooth forceps. Coins with a smooth edge can be grasped with rubber-coated prongs.

Instruments
Apart from pediatric and therapeutic upper endoscopes, the endoscopic armamentarium should include a variety of forceps (crocodile, rat-tooth, etc.), snares, Dormia baskets, and a long overtube.

Technique
An overtube is recommended when removing pointed or sharp objects to avoid damage to the esophagus and pharynx. Small or slippery objects should also be removed through an overtube. It is safest to insert the overtube over a guidewire, using an appropriately sized bougie (generally 45-French) as an obturator. If the foreign body occludes the lumen completely and prevents guidewire placement, then the overtube can be preloaded over the endoscope and pushed into place after the endoscope has been inserted across the pharynx. In such a case, a therapeutic gastroscope should be used to reduce the step formation between the endoscope and the overtube.

Complications
Perforation is the most serious complication that can result from endoscopic foreign body extraction. This usually occurs when removal is difficult or requires excessive force. As

a rule, objects obstructing the esophageal lumen should not be pushed into the stomach. Sharp or pointed objects that can lacerate the mucosa should always be removed through an overtube. Injury to the GI wall, whether due to pressure necrosis, a tear, or a difficult extraction, should be promptly investigated with a radiographic contrast study using a watersoluble contrast agent to rule out a perforation. The possibility of a delayed perforation caused by tissue necrosis should also be kept in mind. Dietary restrictions and acidsuppressive or mucosa-protective drug therapy may be indicated, and the patient (or responsible next of kin) should be informed about the risk of delayed perforation. The risk of a foreign body aspiration during extraction also deserves emphasis. Apart from using an overtube, endotracheal intubation is recommended for patients at increased risk for aspiration. This also includes the patient who is not fasting and particularly if intravenous sedatives are administered prior to the endoscopic procedure.

Bougienage and Balloon Dilation

General
Bougienage or pneumatic dilation is commonly performed for the treatment of benign and malignant strictures of the esophagus, and occasionally for pyloric or colonic strictures. Biliary and pancreatic duct strictures are also amenable to dilation. Repeated dilation is usually necessary to achieve a satisfactory long-term therapeutic result.

Indications
The main indication is a benign, fibrotic stricture of the esophagus. The etiology is usually peptic (recurrent reflux esophagitis) or postoperative (anastomotic stricture). Bougienage is also often indicated prior to stent placement for malignant strictures of the esophagus or bile duct. Benign strictures of the bile duct (postoperative, sclerosing cholangitis) and pancreatic duct (chronic pancreatitis, posttraumatic) are candidates for bougienage or pneumatic dilation if the stricture is short (see Chapter 11, Biliary Stent Drainage, and Chapter 12, Pancreatic Duct Stenting and Stone Extraction). Stenoses in other locations (pylorus, rectum, colon, or gastrointestinal [GI] and biliodigestive anastomoses) are less common indications that require a further workup before general recommendations can be made. The role of endoscopic dilation for strictures of chronic inflammatory diseases such as Crohns disease and diverticulitis needs to be assessed on a patient-to-patient basis, taking into account the endoscopic and radiographic findings and the riskbenefit ratio as compared with surgical options. Pneumatic dilation is an alternative to surgical cardiomyotomy for the treatment of achalasia. Repeated dilations are usually required. Intramural injection of

botulinum toxin is an endoscopic alternative that may achieve results similar to those of pneumatic dilation.

Prerequisites
A preliminary radiographic contrast study is recommended to provide an anatomic road map. A small-diameter gastroscope is used for the initial evaluation. Biopsies are obtained to determine the nature of the stricture. Since a negative biopsy does not rule out malignancy, repeat biopsies may be required after dilation before a stricture can be labeled as benign. The majority of benign strictures require repeated sessions of dilation over a prolonged period of time. Patient education and compliance are therefore important requirements of endoscopic therapy. Patient compliance can be enhanced by minimizing the level of procedural discomfort. Most dilation procedures can be performed under intravenous sedation on an outpatient basis. Procedures are initially repeated at 3- to 4-day intervals and then at 2- to 3- week intervals. Perforation is the most common and dangerous complication that can follow bougienage or pneumatic dilation. Appropriate patient selection, correct choice of instruments, and a cautious technique are the key factors in avoiding perforation.

Fig. 20 Dilation over a hydrophilic guidewire is possible with small-diameter bougies (up to 30-French). The stricture should be inspected after dilation with a smalldiameter endoscope to rule out deeper tears.

Fig. 21a, b The hydrophilic guidewire, which is not as stiff as the metal guidewire, is not suited for bougienage of tight or infiltrating strictures. a A radiopaque 9-French catheter is inserted over the hydrophilic guidewire, through which the hydrophilic wire is exchanged for the more rigid Eder-Puestow wire.

Instruments
The most widely used bougies for esophageal dilation are the flexible Savary-Gilliard bougies made of PVC (polyvinyl chloride). These come in diameters ranging from5 to 20 mm. Bougies made of stiffer plastic material may occasionally be required for extremely tight or infiltrating strictures. The diathermic needle knife, the argon plasma-coagulator, or the Nd:YAG laser can be used to incise fibrotic ring strictures. TTC (through-thechannel) balloon dilators can be inserted through the biopsy channel of the endoscope and are available in diameters ranging from 6 to 25 mm. Larger balloon dilators with diameters of 30, 35, and 40 mm, which are used for the treatment of achalasia, are inserted over a guidewire. An alternative to the balloon dilator is a balloon that is attached to the end of the endoscope. In contrast to balloon dilators, which are made of low-compliance plastic polymers, the balloon attached to the endoscope is made of latex rubber and consists of three layers. Biliary and pancreatic duct strictures can be dilated with Teflon dilators or hydrostatic balloons . Bougienage of strictures initially entails the placement of a Savary-Gilliard guidewire across the stricture through the biopsy channel of the endoscope. The wire is available with or without calibrations, the former wire being mandatory if dilation is performed without fluoroscopy. Hydrophilic guidewires commonly used for the biliary and pancreatic ducts (260 cm

long, 0.035 or 0.038 in, J-shaped tip) are also used for negotiating long, tight, and tortuous strictures.A pediatric endoscope (outer diameter of 5.3 or 7.9 mm) may be necessary to pass a tight or difficult stricture.

Technique
Bougienage should always be performed over a guidewire. Therefore, proper placement of the guidewire is the key to a successful and safe procedure. Balloon dilation with smaller TTC balloons are performed under direct endoscopic guidance. The choice of the balloon or size of the dilator depends upon the tightness of the stricture. This can be judged by the radiologic and endoscopic appearance of the stricture and the resistance encountered during passage through the stricture.

Esophageal Stent Placement

General
Esophageal stenting palliates obstructive symptoms caused by tumors of the esophagus and the cardia. Stent placement not only relieves dysphagia, thus enabling oral nutrition, but also prevents aspiration pneumonitis. Tracheoesophageal fistulae, too, can cause similar complications. The major advantage of stent placement over other palliative treatments is the prompt relief of dysphagia.

Indications
The primary indications are dysphagia and tracheoesophageal fistulae due to advanced, unresectable, or inoper-able tumors of the esophagus and cardia. Less scommon indications are strictures at other sites, such as the distal stomach or rectum, that fulfill criteria in which palliative surgery is either not feasible or too hazardous.

Prerequisites
Fundamental prerequisites for stent placement are confirmation of malignancy on biopsy and unresectability on imaging studies. The palliative objectives should be well defined and the symptoms should correspond to findings on radiologic and endoscopic imaging (including endosonography and bronchoscopy). Despite the larger diameter of self-expandable metal stents, palliation of dysphagia may not be superior. Peristalsis an important component of swallowingis impaired by the tumor as well as the stent. Thus, a larger stent diameter may not necessarily enhance the patients ability to swallow.

A reasonable goal of treatment is the ability to swallow a soft pureed diet, for which an inner stent diameter of 10mm usually suffices. In the literature plastic stent placement has been complicated by high perforation rates, partly due to the need for extensive bougienage prior to stenting. Selecting a plastic stent with a smaller diameter (10 mm), soft material, and proper technique (see following text, Technique) will minimize the risk of perforation. Plastic and expandable stent placement requires preliminary dilation of the tumor stenosis. To avoid perforation, bougienage should be performed gradually and, if necessary, in several sittings. Excessive dilation should be avoided to prevent subsequent migration of the stent.

Fig. 34 Instruments for plastic stent placement: bougie with the Savary-Gilliard guidewire, transparent pusher tube with markings in centimeters, and a plastic stent.

Instruments
A variety of plastic (silicon, latex, Tygon) and self-expanding metal (stainless steel, nitinol) stents are available for the treatment of tumors obstructing the esophagus and/or cardia . Self-expandable stents are covered to prevent tumor ingrowth. The expandable stents differ in their expansile force, flexibility, release mechanisms, radiographic visibility, and retrievability. Expandable stents equipped with anti-reflux mechanisms (valve, windsock) have been designed for low esophageal or cardia strictures. Plastic stents may need to be modified to accommodate special anatomic situations. For cervical esophageal strictures a stent with a short funnel and a small diameter (outer diameter of less than 10 mm) is used to avoid or minimize foreign body sensation and tracheal compression. For distal esophageal or cardia strictures a stent with distal flaps to prevent proximal migration is used (Fig. 33). To seal off a fistula, a stent with a wide funnel is used (this can be achieved by adding a second funnel). Silicone flaps and a second funnel are added to the stent with a fast-acting glue. Fluoroscopy is required to guide expandable stent placement, but is not mandatory for the insertion of a plastic stent. A 29-French bougie serves as an introducer for a stent with an internal diameter of 10 mm, inserted over a Savary-

Gilliard guidewire. The stent is advanced with a 14- mm calibrated pusher tube (Fig. 34).

Percutaneous Endoscopic Gastrostomy (PEG)

General
Percutaneous endoscopic gastrostomy (PEG) is the intentional formation of a gastrocutaneous fistula for the purpose of enteral feeding. It has gained widespread popularity because it is technically easy, rapid, and safe. It is preferable to nasoenteral feeding tubes for long-term enteral feeding.

Indications
PEG is primarily indicated in patients who are unable to swallow. The causes are usually neurogenic impairment or obstructive tumors of the oral cavity. Less commonly, PEG may be indicated for nutritional support of the undernourished patient with gross anorexia.

Prerequisites
Percutaneous transgastric nutrition requires a patent bowel. This can usually be determined from the patients history. Gastric outlet obstruction should be ruled out on an upper gastrointestinal (GI) endoscopy. Residual food or secretions in the stomach or duodenum in the fasting patient signal the possibility of outlet obstruction. Stenoses in the oropharynx and esophagus may require a preliminary bougienage. An absolute prerequisite for PEG is a close contact between the anterior wall of the stomach and the abdominal wall. Interposed viscera are excluded by transillumination through the abdominal wall with the endoscope. Hepatomegaly can also impede PEG and is excluded by physical examinationPortal hypertension increases the risk of bleeding during PEG and should consequently bewatched out for and tested for. Preoperative broad spectrum antibiotics are generally recommended as a prophylaxis against infection. The abdomen is prepared and draped as for an abdominal operation. The key to avoiding complications is proper postoperative careespecially during the firstweekuntil the parietal and visceral peritoneum have fully adhered. Tube feeding can be started on the same day as placement if the tube is properly positioned and anchored.

Fig. 42 Assuming normal GI anatomy, the puncture site is approximately 23 fingerbreaths under the left costal margin in the paramedian line. In the patient with a Billroth II operation, the puncture site is along the left costal margin.

Instruments
Gastrostomy sets differ according to the technique used. The pull technique is the most commonly used. In general, a 15- French feeding tube is adequate for instilling commercially available enteral nutrition preparations. Most PEG tubes have an internal bolster measuring approximately 2.5 cm in diameter and can be fixed to the abdominal wall by an adjustable external bolster. Antiseptic solution, scalpel, gauze dressing, and various adaptors for the feeding tubes are usually supplied in most commercially available kits. A special 110-cm-long 9-French tube is also available for placement in the jejunum (percutaneous endoscopic jejunostomy). PEG is performed using a standard diagnostic gastroscope with a 2.8-mm working channel. The thread can be grasped with a biopsy forceps or polypectomy snare. A rattooth forceps is necessary for placing a jejunal feeding tube.

Technique
In the more popular pull technique, the PEG tube is pulled through the oropharynx with the aid of an attached thread that pulls it out through the stomach and abdominal wall. Using the push technique, the tube is percutaneously inserted directly into the stomach over a guidewire. Although the push technique is a more direct approach, it requires serial dilation of the puncture tract to allow insertion of the PEG tube and is thus more complicated and involves more risk than the pull technique. The procedure begins with a standard esophagogastroduodenoscopy in the left lateral position. Stomach contents are cleared with endoscopic suction.

Enteral Tube Placement

General
Tubes are endoscopically placed into the jejunum either to enable enteral feeding or to decompress the small bowel. A tube can also be inserted into the colon to decompress it.

Indications
A jejunal tube is indicated for enteral feeding when gastric emptying is impaired because of mechanical obstruction or a motility disorder. Long-term jejunal feeding warrants a percutaneous endoscopic gastrostomy (PEG) through which the feeding tube is inserted. A jejunal tube is also indicated for small-bowel decompression in patients with unclear intestinal obstruction (e.g., ileus in the early postoperative phase). Tube decompression of the colon is indicated for colonic pseudo-obstruction.

Prerequisites
Bowel decompression should not be an excuse for postponing a necessary operation. This applies particularly to mechanical intestinal obstruction. Distal propagation of the Dennis tube requires at least some peristaltic activity. In the setting of a complete adynamic ileus, a Dennis tube is no better than a nasogastric tube. Endoscopic decompression of colonic pseudo-obstruction is indicated when the risk of surgery is considered to be prohibitively high.

The feeding tube is advanced under direct vision into the jejunum. The wire is then withdrawn until it lies about 5 cm beyond the endoscope. This will prevent the tube from kinking.

Instruments
A pediatric gastroscope (outer diameter 5.9mm or 7.9 mm) is used to position a guidewire for over-the-wire insertion of an enteral tube. A therapeutic gastroscope with a 3.7-, 4.2-, or 6-mm working channel is used for through-the-scope (TTS) placement of enteral tubes. A variety of enteral tubes are available: Feeding tube: 250 cm long, 9-French, with adapter Dennis tube for small-bowel decompression: 210 cm long, 16-French triple-lumen tube with a balloon at the tip Colonic decompression tube: 130 cm long, 24-French polyethylene tube inserted over a 300 cm long, 7-French radiopaque Teflon delivery catheter Accessories required are Teflon-coated stainless steel and hydrophilic guidewires (400 cm long, 0.035 in) and a large rat-tooth forceps to grasp the Dennis tube and advance it into the duodenum.

Technique
The TTS technique is the easiest and fastest method of placing feeding tubes. A 9French feeding tube, stiffened with a0.035-in Teflon-coated guidewire, can be inserted through a gastroscope with a 3.7-mm working channel (Fig. 60). Overthewire placement is performed if a large-channel gastroas

ANGIOPLASTY

What is angioplasty? What is the benefit of having angioplasty? What causes blockages in the arteries? Why do I need angioplasty? What should I expect before my angioplasty? What happens during my angioplasty? What should I expect after the procedure?

What is angioplasty?
Angioplasty is a minimally-invasive procedure that repairs and restores blood flow through a narrowed or blocked artery in the heart. The procedure is performed by an interventional radiologist.

What is the benefit of having angioplasty?

Angioplasty can prevent a heart attack or stoke by opening your blocked artery, restoring blood flow to your tissues and relieving your symptoms without the need for surgery.

What causes blockages in my arteries?

Blockages in arteries and veins can be caused by smoking, high cholesterol levels, diets high in saturated fats, and cardiovascular disease.

Why do I need angioplasty?

The most common reason for angioplasty is to relieve a blockage of an artery caused by atherosclerosis, or hardening of the arteries. Atherosclerosis is a gradual process in which cholesterol and other fatty substances in the bloodstream form a substance called plaque on the inside of the blood vessel walls and clog the artery. When medications or lifestyle changes arent enough to reduce the effects of blockages in your arteries, or if you have worsening chest pain or heart problems your doctor may suggest angioplasty. If you have extremely hard plaque deposits, blockages, or blood vessel spasms that dont go away, you probably are not a good candidate for angioplasty.

What should I expect before my angioplasty?

Prior to the procedure, you may have several tests performed, such as X-rays and blood tests. You will be asked not to eat or drink anything after midnight the night before your procedure. You should tell the interventional radiologist or nurse if you are allergic to any medications. Angioplasty usually requires an overnight hospital stay. Make sure you arrange for transportation home.

What happens during my angioplasty?

Angioplasty is performed by a specially-trained doctor, called an interventional radiologist. The interventional radiologist will use an intravenous (IV) line to give you fluids and medicines that will relax you and prevent blood clots. Next the nurse will:

Shave the area where the catheter or tube will be inserted, usually the arm or groin. Clean the shaved area to make it germ free. Numb the area.

When you are comfortable, the interventional radiologist will begin the procedure.

A small incision is made in the skin to find an artery. The doctor then threads a very thin wire through the artery up to the coronary artery that is blocked.

When the wire reaches the area of the blockage, a tube (called a catheter) with a deflated balloon on the end is threaded into the blocked artery under X-ray guidance. A small amount of dye may be injected through the tube into the blood stream to help show the blockage on X-ray. This X-ray picture of the heart is called an angiogram. When the tube reaches the blockage, the balloon is inflated. The expanding balloon forces the blockage to open by pushing the walls of the artery outward, increasing blood flow to the heart muscle. A stent usually is placed at the site to keep the artery open. Once the balloon has been deflated and withdrawn, the stent remains in place permanently, holding the blood vessel open and restoring blood flow to the arteries.

What should I expect after my procedure?

Your catheter site will be checked for bleeding and swelling after the procedure. Your blood pressure and heart rate will be monitored. Your physician may prescribe medication to relax you and protect your arteries against spasm and to prevent blood clots. Usually you will stay at the hospital overnight and return home the day after the procedure. You typically will be able to walk within two to six hours following the procedure and return to your normal routine by the following week.

The Facts on Angioplasty

Angioplasty is a technique for reopening narrowed or blocked arteries in the heart (coronary arteries) without major surgery. First used in 1977, it's now as common as heart bypass surgery. It's sometimes called percutaneous transluminal coronary angioplasty (PTCA) or percutaneous coronary intervention (PCI). "Angio" means relating to a blood vessel and "plasty" means repair. Angioplasty is also used in other parts of the body, usually to treat peripheral artery disease.

Before the operation

You shouldn't eat after midnight on the night before your angioplasty. Ask your doctor if you can drink clear liquids after this. You can usually continue to take your medications, but you should discuss this with your doctor. Check with your doctor if you take blood thinners such as warfarin, as you may need to stop them 5 days before the procedure. If you take insulin, you may have to adjust the dose. You must also tell your doctor if you are allergic to iodine or shellfish, since angioplasty involves injecting you with an iodine-based dye. You may have to go for some preliminary blood tests. Your doctor may tell you to not smoke for a period of time before or after angioplasty. For best results, you should quit smoking permanently.

The procedure
Angioplasty is performed while you are awake, under local anesthetic. It's sometimes uncomfortable, but not usually painful. The surgeon makes a small incision in the groin or arm and inserts a thin tube, called a catheter, into the artery. The catheter includes a small balloon and a small wire tube, called a stent. Once the catheter is in place, a dye is injected and X-rays are taken, which tell the physician exactly where the blockages are and how narrow the artery is. This is also known as an angiogram and functions as a map for the doctor. The doctor will then inflate the balloon, opening the stent and pushing it against the artery wall. After the procedure is complete, the cells that line the blood vessel will grow around the stent, holding it in place. The whole procedure usually lasts 30 minutes but may last as long as several hours. Sometimes, people will have to return to get their arteries redone because of renarrowing (restenosis) at the site of the balloon inflation.

There are other types of angioplasty sometimes used in combination with the balloon:

Drug-coated stents are specially-treated stents that gradually release a special medication into the wall of the artery after they have been put into place and inflated. They reduce the risk of needing another procedure and are used for people who have a high risk of developing renarrowing of the artery after the initial procedure. These stents may increase the rare risk of clotting. Studies are ongoing to identify safety and outcomes of the use of these stents. Directional atherectomy involves using a miniature rotating blade to cut out the fatty deposit and remove it from the body. In rotational atherectomy, a diamond-studded drill bit is used to pulverize tough blockages.

Intracoronary radiation involves irradiation of the section of artery after balloon angioplasty. Studies show this experimental technique reduces restenosis in your artery by 70%.

After the operation

Most people are admitted to hospital and monitored overnight after angioplasty. They are usually sent home early the next day. Once home, avoid any type of lifting or other strenuous physical activity for a week. Your doctor will advise you when you will be able to return to work and resume driving and other physical activity. If you have a stent, you will usually have to take an extra blood thinner medication such as clopidogrel in addition to acetylsalicylic acid for at least the first few months in order to prevent blood from clotting on the metal stent. This treatment may continue for one year. You may also have to put off dental work for several months due to the risk of endocarditis (an infection of the heart). Call your doctor if you:

experience swelling, bleeding, or pain at the insertion site develop a fever notice a change in temperature or colour in the arm or leg that was used feel faint or weak have shortness of breath or chest pain

Angioplasty or coronary arteries bypass surgery?

Coronary artery bypass grafting (CABG) is a successful but more invasive technique for restoring blood flow to the heart. The heart is usually stopped and chilled, and the patient is kept alive by a heart-and-lung machine. Usually strips of vein are removed from one or both of the patient's own legs to be used as bypass grafts. The great advantage of angioplasty is that the artery is returned to normal size without resorting to major surgery. The drawback to angioplasty is restenosis. This is when the artery renarrows due to scar formation and possibly further plaque formation. If the angioplasty lasts six months, there's a good chance it's permanent, but restenosis is far more likely after angioplasty than after a CABG. On the other hand, angioplasty allows people to come back for more treatment. If an artery re-narrows after CABG, there may not be enough vein or artery segments elsewhere in the body to perform a second graft. Moreover, a second angioplasty is far less traumatic to the body than a second open heart procedure.

Sometimes, circumstances will make the choice for you. People with many severe blockages, multiple coronary blockages, or those who have diabetes may be better off with CABG. Also, most hospitals don't perform angioplasty if there are several major arteries blocked. This is because angioplasty temporarily blocks the artery completely when the balloon is inflated. If the other arteries are also blocked, this could trigger a heart attack. However, if you're over 80 years of age or have other serious medical problems, you may be considered too vulnerable for the trauma of open-heart surgery. In that case, angioplasty may be a more attractive option, no matter how many arteries are blocked.

Possible complications

Angioplasty is safer than bypass surgery. Less than 1% of people die from complications of angioplasty. Non-fatal serious complications occur in 1% to 5% of people who undergo this procedure. These complications include:

tearing of the lining of the artery resulting in total blockage and possible heart attack - this can usually be repaired with a stent stroke from a clot that is dislodged while the catheter is inside the body bleeding or bruising kidney problems, especially in people with underlying kidney disease and diabetes - this is caused by the iodine contrast dye used for the X-ray; intravenous fluids and medications can be given before and after the procedure to try to reduce this risk

All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For more information on brand names, speak with your doctor or pharmacist.

What Are the Risks of Coronary Angioplasty?

Coronary angioplasty is a common medical procedure. Serious complications don't occur often. However, they can happen no matter how careful your doctor is or how well he or she does the procedure. Serious complications include:

Bleeding from the blood vessel where the catheters were inserted. Blood vessel damage from the catheters.

An allergic reaction to the dye given during the angioplasty. An arrhythmia (irregular heartbeat). The need for emergency coronary artery bypass grafting during the procedure (24 percent of people). This may occur if an artery closes down instead of opening up. Damage to the kidneys caused by the dye used. Heart attack (35 percent of people). Stroke (less than 1 percent of people).

Sometimes chest pain can occur during angioplasty because the balloon briefly blocks blood supply to the heart. As with any procedure involving the heart, complications can sometimes, though rarely, cause death. Less than 2 percent of people die during angioplasty. The risk of complications is higher in:

People aged 75 and older People who have kidney disease or diabetes Women People who have poor pumping function in their hearts People who have extensive heart disease and blockages in their coronary (heart) arteries

Research on angioplasty is ongoing to make it safer and more effective, to prevent treated arteries from closing again, and to make the procedure an option for more people.

Complications From Stents:

Restenosis
After angioplasty, the treated coronary artery can become narrowed or blocked again, often within 6 months of angioplasty. This is called restenosis (RE-sten-o-sis). When a stent (small mesh tube) isn't used during angioplasty, 4 out of 10 people have restenosis. The growth of scar tissue in and around a stent also can cause restenosis. When a stent is used, 2 out of 10 people have restenosis.

Stent Restenosis

The illustration shows the restenosis of a stent-widened coronary artery. In figure A, the expanded stent compresses plaque, allowing normal blood flow. The inset image on figure A shows a cross-section of the compressed plaque and stent-widened artery. In figure B, over time, scar tissue grows through and around the stent. This causes a partial blockage of the artery and abnormal blood flow. The inset image on figure B shows a cross-section of the tissue growth around the stent. Stents coated with medicine reduce the growth of scar tissue around the stent and lower the chance of restenosis even more. When these stents are used, about 1 in 10 people has restenosis. Other treatments, such as radiation, can help prevent tissue growth within a stent. For this procedure, a wire is put through a catheter to where the stent is placed. The wire releases radiation to stop any tissue growth that may block the artery.

Blood Clots
Studies suggest that there's a higher risk of blood clots forming in medicine-coated stents compared to bare metal stents. However, no conclusive evidence shows that these stents increase the chances of having a heart attack or dying, if used as recommended. When medicine-coated stents are used in people who have advanced CHD, there is a higher risk of blood clots, heart attack, and death. Researchers continue to study medicine-coated stents, including their use in people who have advanced CHD. Taking medicine as prescribed by your doctor can lower your risk of blood clots. People who have medicine-coated stents usually are advised to take anticlotting medicines, such as clopidogrel and aspirin, for months to years to lower the risk of blood clots. As with all procedures, it's important to talk with your doctor about your treatment options, including the risks and benefits.

Key Points

Coronary angioplasty is a procedure used to open blocked or narrowed coronary (heart) arteries. The procedure improves blood flow to the heart muscle. Over time, a fatty substance called plaque can build up in your arteries, causing them to harden and narrow. When plaque builds up in the coronary arteries, the condition is called coronary heart disease (CHD). Angioplasty can restore blood flow to the heart if the coronary arteries have become narrowed or blocked because of CHD. The procedure can improve symptoms of CHD, reduce damage to the heart muscle caused by a heart attack, and reduce the risk of death in some patients. Angioplasty is less invasive than surgery. General anesthesia isn't needed. You'll be given medicines to help you relax, but you'll be awake during the procedure. Before angioplasty is done, your doctor will need to know the location and extent of blockages in your coronary arteries. To find this information, your doctor will use coronary angiography. This test uses dye and special x rays to show the insides of your coronary arteries. Angioplasty is done in a special part of the hospital called the cardiac catheterization laboratory. During angioplasty, your doctor will use a thin, flexible tube called a catheter with a balloon at the end. He or she will thread the balloon catheter through an artery in your arm or groin (upper thigh) to the blockage in your coronary artery. Your doctor will then inflate the balloon. This pushes the plaque against the artery wall, relieving the blockage and improving blood flow.

A small mesh tube called a stent usually is placed in the newly widened part of the artery. The stent helps prevent the artery from becoming narrowed or blocked again. The stent remains in place after the procedure. After the procedure, you'll be moved to a special care unit. While you recover, nurses will check your heart rate and blood pressure. Most people go home the day after having angioplasty. Your doctor may recommend lifestyle changes after angioplasty to improve CHD and to prevent arteries from becoming narrowed or blocked again. Lifestyle changes may include changing your diet, quitting smoking, doing physical activity regularly, losing weight or maintaining a healthy weight, and reducing stress. You also should take all of your medicines exactly as your doctor prescribes. Angioplasty is a common medical procedure. Serious complications don't occur often. However, they can happen no matter how careful your doctor is or how well he or she does the procedure. Complications may include bleeding, renarrowing of the artery, blood clots, and more. Research on angioplasty is ongoing to make it safer and more effective, to prevent treated arteries from closing again, and to make the procedure an option for more people. Re-narrowing of your artery (restenosis). With angioplasty alone without stent placement restenosis happens in as many as 30 to 40 percent of cases. Stents were developed to reduce restenosis. The original bare-metal stents reduce the chance of restenosis to less than 20 percent, and the use of drug-eluting stents has reduced the risk to less than 10 percent. Blood clots. Blood clots can form within stents even weeks or months after angioplasty. These clots may cause a heart attack. It's important to take aspirin, clopidogrel (Plavix) and other medications exactly as prescribed to decrease the chance of clots forming in your stent. Talk to your doctor about how long you'll need to take these medications and whether they can be discontinued if you need surgery. Bleeding. You may have bleeding at the site in your leg or arm where a catheter was inserted. Usually this simply results in a bruise, but sometimes serious bleeding occurs and may require blood transfusion or surgical procedures.

Other rare risks of angioplasty include:

Heart attack. Though rare, you may have a heart attack during the procedure.

Coronary artery damage. Your coronary artery may be torn or ruptured (dissected) during the procedure. These complications may require emergency bypass surgery. Kidney problems. The dye used during angioplasty and stent placement can cause kidney damage, especially in people who already have kidney problems. If you're at increased risk, your doctor may give you a medication to try to protect your kidneys. Stroke. During angioplasty, blood clots that may form on the catheters can break loose and travel to your brain. Blood thinners are given during the procedure to reduce this risk. A stroke can also occur if plaques in your heart break loose when the catheters are being threaded through the aorta. Abnormal heart rhythms. You heart may get irritated during the procedure and beat too quickly or too slowly. These heart rhythm problems are usually short-lived, but sometimes medications or a temporary pacemaker is needed.