Angioplasty & Stenting
WHAT ARE ANGIOPLASTY & STENTING?
Angioplasty is the procedure of using a balloon catheter to dilate an artery that is abnormally narrowed, usually by fatty plaque or cholesterol. Stenting is performed after the angioplasty and involves inserting a metallic framing device in the artery to keep it open. The stent bears some rough resemblance to Chinese handcuffs. The stent is basically a tube made out of a wire screen material, which fits inside the artery to keep it open and allows blood to pass through the center of the tube. We have demonstration products and will be glad to show these to you. Angioplasty and stenting are performed as a continuation of a cerebral angiogram. Another pamphlet describes angiography, and it would be helpful if you are familiar with angiography before reading this description.
The procedure of angioplasty and stenting was performed on the heart blood vessels of our Vice President, Dick Cheney, and his procedure is very similar to what is described herein, although in your case involving arteries in the neck and brain, rather than the heart.
WHY SHOULD I HAVE ANGIOPLASTY & STENTING?
If an artery supplying blood to your brain becomes narrowed by atheromatous plaque (fat and cholesterol), trauma or other causes, blood flow to the brain is reduced compared to an artery that is not narrowed. If flow is decreased enough, you can have a stroke. A stroke is what happens when the brain is deprived of blood, that part of the brain can be damaged or die. These types of stroke can cause paralysis, inability to talk, blindness or difficulty speaking. Your doctors have evaluated the arteries supplying your brain and feel you are at risk of having a stroke because at least one of them is narrowed to a significant degree.
HOW IS ANGIOPLASTY & STENTING PERFORMED?
With the catheter in place from the angiogram, a balloon catheter is navigated through the inside of the catheter already in the artery in your leg, and out the tip. From this point the balloon catheter is carefully navigated through blood vessels to the narrowed artery. We confirm the balloon catheter is in the correct artery by injecting contrast dye and taking pictures. The balloon is inflated and that pushes the plaque against the wall of the artery which opens it, usually to about the normal size. The plaque is compressed similar to the way snow is compressed by skis. The plaque is not removed but compressed. The balloon catheter is then removed, and another catheter with the stent attached to it is then navigated to the narrowed area. The very small stent is tightly attached to the catheter. After it is in the correct location, the stent is then opened up inside the artery and expands snugly against the inside of the artery. The stent keeps the artery from collapsing back down and pieces of the plaque from dislodging and going to the brain. After the stent is opened up the catheters are removed and the procedure is finished.
WHY DO YOU USE A STENT IN THE ARTERY?
The stent makes the procedure much safer by keeping the artery open and holding the plaque in place against the wall of the artery.
WHAT IS THE STENT MADE FROM AND WILL IT CAUSE PROBLEMS?
The stent is made of a metal that will never deteriorate, rust, or break down. It does not cause any allergies. You can have an MRI after the stent is placed.
CAN THE STENT MOVE AFTER IT IS IN PLACE?
No, once the stent is opened up it cannot move to any other artery.
WHAT IF SOMETHING BREAKS OFF AND GOES TO MY BRAIN?
This problem is a cause for concern and is dealt with in several ways. The chance of it happening is greatly reduced by your taking aspirin and Plavix before the procedure. Discuss those medications with us. In addition, during the procedure your blood is thinned with heparin, and that medication also greatly reduces the risk of a stroke. For carotid artery angioplasty, we generally use filter device downstream from the stented area that can capture any of these broken particles, and keep them from plugging up brain arteries. The filter is removed at the end of the procedure.
DOES THE PROCEDURE HURT AND AM I GIVEN PAIN & RELAXATION MEDICATIONS?
You will have no sensation of the balloon catheter and stent moving through the arteries. When the artery in the neck is opened by the balloon it is common to feel some discomfort in the neck that goes away quickly after the balloon is removed. You will not feel the stent opening up. Most patients are nervous beforehand, and we tend to give a lot of sedation just so it is not a miserable experience for you. If angioplasty and stents are being placed in blood vessels in the brain you will be given a general anesthetic and will be asleep.
HOW MANY TIMES HAVE YOU DONE ANGIOPLASTY & STENTS?
The Neurointerventional Service at OHSU, with Drs. Barnwell, Petersen, Nesbit, Lee and Dogan have performed well over one thousand intracranial procedures in the 15 years this service has been active, by far the most experience of any neurosurgical group in the Pacific Northwest, or just about anywhere in the United States. Angioplasty and stenting is one of our most common procedures. We have placed over 1000 angioplasties in patients over the past 15 years. The Neurointerventional Service at OHSU is the nations leader in enrolling patients in FDA approved stenting trials currently taking place. The procedure is performed as a team effort coordinating specially trained doctors, nurses, and technologists.
I READ THE RISKS OF A CEREBRAL ANGIOGRAM, ARE THERE OTHER RISKS WITH ANGIOPLASTY & STENTING?
The risk of angioplasty and stenting, like a cerebral angiogram, is very low. Left untreated your doctors feel your risk of a stroke is higher if you don't have the procedure than if you have this procedure. The procedure does have risk of causing what we are trying to prevent, a stroke, which can be life-threatening. If during the course of this procedure we felt your risk of complication was higher than normal, we would stop the procedure and not treat you with a stent, but would pursue other options such as increasing your medications.
The long-term effectiveness of stents is better understood now than in the past, and is a very durable therapy. There may be less chance of recurrent narrowing after a stent has been placed compared to surgical treatments. However, some patients develop a scar inside or next to the stent that can lead to narrowing. If this occurs and your doctors feel it is necessary to retreat you, the procedure can be repeated relatively easily.
Some patients have changes in their blood pressure after this procedure, usually it is lower than before the procedure. Adjustments of your medications to account for this change may prolong the time you are in the hospital.
The tube or catheter in the artery in your leg is larger than our usual catheters. We take precautions to insure the artery is not damaged by these catheters, or that you do not have more bleeding, but this also remains with some risk.
HOW SHOULD I PREPARE FOR THE PROCEDURE?
We usually want you to be taking aspirin (325 mg, one adult tablet) and Plavix (75 mg), a prescription medication, five days before the procedure, including the morning of the procedure. These medications are very important and you need to make sure you are taking them. If you are not on them prior to the procedure we can give it to you the morning of the procedure, but we prefer to treat you earlier.
WHAT SHOULD I DO THE DAY OF THE PROCEDURE AND WHAT ABOUT MY FAMILY/FRIENDS?
You will be given a time to come to the hospital, and you should go to the 9th floor admissions desk at OHSU Hospital at that time. Be aware there may be a delay between the time you arrive and the time your procedure starts. This may be several hours. Bring a book to read (suggested reading: A Tale of Two Cities). Unless you are having a general anesthetic, and we would discuss that with you ahead of time, you may have some coffee or juice the morning of the procedure, and maybe a little toast. Some people get a little nauseated, so hold off the country ham and eggs on this day. You should take your regular medications, including and especially the aspirin and Plavix. Your family can accompany you all the way into the angiogram suite. During your procedure we would like them to wait on the 11th floor, by the elevators in the family waiting area, so we can keep them informed.If the phone rings answer it, we may be trying to call out and give you an update.
HOW LONG DOES THE PROCEDURE TAKE?
Generally these procedures take one to two hours.
WHAT HAPPENS AFTER THE PROCEDURE?
You will spend the first night after the procedure in an intensive care. We admit patients to the ICU to closely monitor blood pressure, vital signs, and your neurological exams. Your family can see you once you are settled in that unit. If you have any discomfort you should ask for pain medicines. Most patients can leave the next day.
WHAT SORT OF FOLLOW-UP WILL I HAVE AFTER THE PROCEDURE?
We may obtain an ultrasound of your neck blood vessels within a week of the procedure, either at OHSU or by your family doctor. This test can be repeated at six months to look for any narrowing within the stent. It is best if that test is done at the same facility and by the same technologists. So, wherever you have your first ultrasound, have the follow-up at the same place.
For medications we generally want you to be on one adult aspirin (325 mg) each day. We also recommend you take Plavix (75 mg) each day for 30 days. This medication is very similar to aspirin.Make sure you have a supply or prescription of Plavix before you leave the hospital.
Your upper leg area may be sore from where the tubes were inserted. No housework or cooking for a few days until everything feels ok. There may be significant bruising at that site. This will resolve within 1-2 weeks, and even though uncomfortable, is not a problem unless there is an expanding mass or bump at the groin.
CAN I HAVE AN MRI OR CT AFTER AN ANGIOPLASTY & STENTING PROCEDURE?
Yes, it is safe to have either of these tests after this procedure. The stent may cause a shadow on the MRI and reflection on a CT.
IS THERE RESEARCH ONGOING REGARDING ANGIOPLASTY & STENTING?
Yes, and a lot of it is done here at OHSU and the Department of Neurological Surgery. We are involved in a number of trials evaluating improved stents. There is a high likelihood you may be enrolled into a trial if a stent is going to be used. We will discuss that issue with you in detail.
IS ANGIOPLASTY & STENTING AN FDA APPROVE PROCEDURE?
For carotid angioplasty, the procedure has been recently approved by the FDA (September, 2004). The FDA has not evaluated angioplasty and stenting of arteries inside the brain or vertebral arteries. Your doctors are treating you with this technique because they feel it is the best therapy for your narrowed arteries.
WHAT IF I DO NOT WANT A STENT ARE THERE OTHER OPTIONS?
Some lesions in the neck can be treated by surgery, called a carotid endarterectomy. You should fully explore this option before considering angioplasty and stenting. You could also continue medical therapy.
WILL INSURANCE PAY FOR THE PROCEDURE?
If you are involved in a trial of carotid artery stenting, your Medicare insurance will usually cover the cost like any other procedure. If you are not part of a study, insurance may not pay all of the cost and you may be responsible for some part of the bill. We will discuss this with you before the procedure.
HOW CAN I REACH YOU AFTER THE PROCEDURE?
During the day we can be reached at 503-494-7736.
If it is after hours please call the paging operator at 503-494-9000 and ask for the Neurointerventional services or the Neurosurgeon on call to be paged.
If it is an emergency go to the nearest emergency room.
