Complicating Tears during Coronary Angioplasty: Where are they Most Prevalent and how do They Affect Patient Outcomes?
Researchers from Thomas Jefferson University Hospital discovered that blockages in the right coronary artery and those in bending areas of the coronary artery are the most common places for coronary dissection, a tear in the artery that can occur during balloon angioplasty of the coronary arteries.
They will present their findings at the American College of Cardiology annual meeting in Chicago on Saturday, March 24 at 9 AM.
A ‘controlled tear’ is the mechanism by which angioplasty dilates the blocked vessels. A large tear, or spiral dissection, that continues almost entirely down the artery, however is associated with serious complications. When such a dissection occurs, the interior wall of the artery is torn, causing it to fold into the path of blood flow and sometimes block flow of blood in the artery altogether.
“This used to cause patients to be rushed to the operating room during angioplasty to open their chest and fix the blockage,” says Rajesh Pradhan, MD, cardiology fellow at Jefferson and first author on the study. Modern technology now allows for stents to be used to open the blockage and repair the torn artery in most cases.
“We wanted to look at these large tears that can dramatically affect blood flow and result in severe complications to understand where they happen most and how good we are at fixing them for our patients,” says Pradhan.
The team retrospectively reviewed 24 cases of spiral dissection and matched them against a control group of patients without dissection.
Coronary Angioplasty
Coronary angioplasty is a treatment to widen narrowed sections of the coronary (heart) arteries. It is also known as percutaneous coronary intervention (PCI). It does not involve major heart surgery but involves the use of a catheter which is inserted into coronary arteries via the large blood vessels.
Overview
As you age, a waxy substance called plaque (plak) can build up inside your arteries. This condition is called atherosclerosis (ath-er-o-skler-O-sis).
Atherosclerosis can affect any artery in the body. When atherosclerosis affects the coronary arteries, the condition is called coronary heart disease (CHD) or coronary artery disease.
Over time, plaque can harden or rupture (break open). Hardened plaque narrows the coronary arteries and reduces the flow of oxygen-rich blood to the heart. This can cause chest pain or discomfort called angina (an-JI-nuh or AN-juh-nuh).
If the plaque ruptures, a blood clot can form on its surface. A large blood clot can mostly or completely block blood flow through a coronary artery. This is the most common cause of a heart attack. Over time, ruptured plaque also hardens and narrows the coronary arteries.
Angioplasty can restore blood flow to the heart. During the procedure, a thin, flexible catheter (tube) with a balloon at its tip is threaded through a blood vessel to the affected artery. Once in place, the balloon is inflated to compress the plaque against the artery wall. This restores blood flow through the artery.
Doctors may use the procedure to improve symptoms of CHD, such as angina. The procedure also can reduce heart muscle damage caused by a heart attack.
Their analysis showed that the right coronary artery (RCA) was seven times more likely to be complicated by propagating dissection compared to other coronary arteries. Also, lesions (blockage) on a bend of 45 degrees or greater were 12 times more likely to develop a dissection compared to lesions that were not on a bend.
Stenting was successful in treating the dissection in 75 percent of patients. Major in-hospital adverse coronary events (stroke, heart attack, need for emergent bypass surgery, stent thrombosis or death) occurred in 54 percent of patients in the large dissection group and none in the control group. Adverse events in the dissection group included 11 heart attacks, need for emergent bypass surgery in four patients, and one stent thrombosis.
Facts About Angioplasty
- Angioplasty is a procedure that widens narrowed arteries in the heart without the need for major surgery.
- More than a half million angioplasties are performed each year in the United States alone, making it the most common procedure for treating narrowed or blocked arteries and restoring blood flow to the heart.
- More than 1 million angioplasty procedures are performed each year worldwide.
- Dr. Andreas Gruentzig performed the first successful balloon angioplasty in the heart in 1977 in Switzerland.
- In the majority of angoplasty procedures, stents also are used to keep an artery open after it is widened.
- Balloon angioplasty, also called percutaneous transluminal coronary angioplasty (or PTCA), was the original type of angioplasty. Now angioplasty is also done using tiny blades, a drill, or a laser attached to the tip of the catheter, in place of the balloon.
- The first angioplasty procedure launched a new medical subspecialty, interventional cardiology, which focuses on using long, narrow tubes called catheters with a variety of devices on the tip, to treat heart problems without surgery.
“Armed with this knowledge, we can more readily anticipate this complication and be better prepared when treating patients with lesions in these areas,” says Pradhan.
Other authors on the study include: Vignendra Ariyarajah, MD; David L. Fischman, MD; Paul Walinsky, MD; David Ogilby, MD; Babu Jasti, MD; Nicholas Ruggiero, MD; Lisa Moss, RN; Jocelyn Andrel, MSPH and Michael Savage, MD, all with Thomas Jefferson University Hospital.
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About Thomas Jefferson University Hospitals
Thomas Jefferson University Hospitals (TJUH) are dedicated to excellence in patient care, patient safety and the quality of the healthcare experience. Consistently ranked by U.S. News & World Report among the nation’s top hospitals, Thomas Jefferson University Hospital, established in 1825, has over 900 licensed acute care beds with major programs in a wide range of clinical specialties. TJUH is one of the few hospitals in the U.S. that is both a Level 1 Trauma Center and a federally-designated regional spinal cord injury center. TJUH patient care facilities include Jefferson Hospital for Neuroscience, the region’s only dedicated hospital for neuroscience, Methodist Hospital in South Philadelphia, and additional patient care facilities throughout Pennsylvania and New Jersey. TJUH partners with its education affiliate, Thomas Jefferson University.
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Source: Thomas Jefferson University