Estimated Costs for Pediatric Cardiac Surgery / Treatment at World Class Hospital in India

A successful cardiac surgery in children requires an expert medical team - doctors, nurses, and other support staff - who are experienced in such surgeries, can promptly recognize problems and emerging side effects, and know how to react swiftly and properly if problems do arise. A cardiac surgery program will also recognize the importance of providing patients and their families with emotional and psychological support before, during and after the surgery, and will make personal and other support systems readily available to families for this purpose. We make this difficult journey easy for the patient and his relatives.

Paediatric surgeries deal with the correction of abnormalities present in the heart of new-borns, infants or children. Most of the defects are present since birth (congenital). They all come under the category of congenital heart defects. Some are present since birth but cause symptoms after a few years and some cause symptoms immediately after birth.

Major Types of Cardiac Defects in Children :

Any defect in the septum or valves or position of arteries causes mixing of pure and impure blood or reduced blood supply to the body. If the defect is severe it is incompatible with life and requires immediate surgical intervention. Circulation of impure blood in the body results in bluish discoloration of the body called cyanosis. The tissues do not receive adequate amount of oxygen and hence cannot function.

The major cardiac defects include

•       Atrial Septal Defect
•       Ventricular Septal Defect,
•       Fallot’s Tetralogy
•       Valvular defects

   Approximately 25000-30000 children per year are affected by these defects. The paediatric surgeries deal with correction of these malformations.

1

    ASD- Atrial Septal Defect refers to a hole in the septum that separates the right and left atrium. This results in mixing of pure and impure blood.

Depending on the size of the defect, the symptoms may range from no symptoms to bluish discoloration of the body, increase pulmonary blood pressure and irregular cardiac contractions (arrhythmias).

It is corrected by open heart surgery. The sternum is split in the midline. Arterial and double venous (superior vena cava and inferior vena cava) vessels are clamped. By applying cardiopulmonary bypass (heart lung machine), the aorta is clamped, and the heart is temporarily paralyzed by a solution. The right atrium is opened and the defect is sutured.

At our world class hospitals in India, minimally invasive approaches to the repair of ASD have now been developed.  In most cases, the size of the incision is simply decreased with different approaches to cardiopulmonary bypass. Examples include partial or full submammary skin incision, hemisternotomy, and limited thoracotomy. The goal is to improve cosmetic results because these approaches are not associated with decreased morbidity or mortality.

In recent times, ASD have been closed by using a variety of catheter-implanted occlusion devices rather than by direct surgical closure with cardiopulmonary bypass. These devices are placed through a femoral venous approach and are deployed like an umbrella to seal the septal defect. These devices work best for centrally located secundum defects.

Our cardiologist with congenital experience will continue patient care to monitor for recurrence of the shunt and to ensure that the patient has returned to normal activities and cardiac function.

     Ventricular Septal Defect  - is a hole in the wall between the right and left ventricles of the heart. This abnormality usually develops before birth and is found most often in infants. A ventricular septal defect can allow newly oxygenated blood to flow from the left ventricle, where the pressures are higher, to the right ventricle, where the pressures are lower, and mix with un-oxygenated blood. The mixed blood in the right ventricle flows back or recirculates into the lungs. This means that the right and left ventricles are working harder, pumping a greater volume of blood than they normally would. Eventually, the left ventricle can work so hard that it starts to fail. It can no longer pump blood as well as it did. Blood returning to the heart from the blood vessels backs up into the lungs, causing pulmonary congestion, and further backup into the body, causing weight gain and fluid retention. If the VSD is large and surgically uncorrected, pressure can build excessively in the lungs, resulting in pulmonary hypertension. The higher the pulmonary pressure, greater the chances of blood flowing from the right ventricle to the left ventricle, backwards, causing un-oxygenated blood to be pumped to the body resulting in cyanosis (blue skin). The risk for these problems depends on the size of the hole in the septum and how well the infant’s lungs function.

Small VSDs’ are symptomless and closed spontaneously as the child grows. The large VSDs’ cause symptoms like difficulty in breathing and feeding, poor growth and pallor. The symptoms occur due to the increase in size of the right ventricle (right ventricular hypertrophy) and increase in pressure inside the lungs (pulmonary hypertension).

Two types of surgeries are available -

a) Intra-Cardiac Technique – the patient is attached to an external heart-lung machine (which performs circulatory and respiratory function during surgery). It is an open heart surgery in which the patient is placed under general anaesthesia. The rib cage is cut open in the midline. The heart is directly accessed and the defect is sutured.

                        

   b) Trans- Catheter Technique – Surgical instruments are passed through the catheter which is inserted in the femoral artery at the groin. The catheter is slowly guided up towards the point of defect to close it. It is a successful surgery.

                        With the separation of ventricles normal circulation resumes. The enlarged heart comes back to normal size. Pulmonary artery pressure reduces. The child’s growth fastens. The prognosis is excellent.

     FALLOT’S TETRALOGY: it is the most common congenital heart defect in children. The defect results in mixing of pure and impure blood.

It comprises a combination of four defects- right ventricular hypertrophy (increase in the size of right lower chamber), ventricular septal defect (whole in the wall between the two ventricles), abnormal position of aorta (aorta is on right side of heart instead of the left) and pulmonary stenosis (narrowing of pulmonary valve opening which prevents outflow of blood from right ventricle).

Two major surgeries help to correct these abnormalities.

Blalock- Taussig’s operation is a palliative procedure performed in smaller infants to increase blood flow to lungs and to allow the child to grow big enough to withstand the corrective surgery. A connection is made between right subclavian artery and pulmonary artery to pass more oxygenated blood to the latter. This relieves the cyanosis to a great extent.

The total corrective surgery is performed in children within 2 years of age. VSD is closed with a patch and the narrowed pulmonary valve is opened. The outcome of surgery is favourable and most children lead a healthy life after the surgery with minimum restrictions. 

     Double valve repair and replacement- valves are openings between two chambers and also between a chamber and artery which allows unidirectional flow of blood. The patency of these valves is very important for normal flow of blood. The function of mitral valve (between left atrium and left ventricle) and the aortic valve (between left ventricle and aorta) is very important. If these valves get narrowed, the amount of blood passing from left atrium to left ventricle (mitral valve) or from left ventricle to aorta (aortic valve) is drastically reduced. In this case the heart will pump blood harder to push it through the narrowed valves. But the blood will tend to go upwards back into the pulmonary vein and finally to the lungs. This will cause excess blood in the lungs leading to congestion. At the same time very less blood will come out into the aorta from the left ventricle which will result in reduced blood and oxygen supply to all the body parts.

5.     

Double valve repair and replacement procedure aims at correcting or replacing these both these damaged valves (aortic & mitral together) with new functional valves.  This is done through the open heart surgery. The patient is put under general anaesthesia and connected to the heart lung machine. This machine takes over the pumping, circulatory, and respiratory functions of the heart and lung till the surgical procedure is going on. The valves are accessed by cutting open the rib cage and accessing the heart directly. The old valves are sliced from their attachments and new valves are put in their place. The new valves may be obtained from a cadaveric donor, or an animal (pig) or it may be made of a nonreactive inert material. The patient needs to be given anticoagulants or immunosuppressive to clotting of blood or rejection of organ. The prognosis of this surgery is good. It is many a time a life-saving and life extending surgery.

Estimated Costs for  Heart Surgery/ Treatment  at World Class Hospital in India

Open Heart Surgery + Angiography – 7000  US Dollars

Open Heart Surgery + Angiography + Conduit -   13500 US Dollars

Closed Heart Surgery + Angiography + Shunt – 7800 US Dollars

Valvuloplasty -  2300 US Dollars

PDA Device Closure – 6900 US Dollars

Heart Valve Repair or Replacement Surgery at World Class Hospitals in India

Blood is pumped through your heart in only one direction. Heart valves play a key role in this one-way blood flow, opening and closing with each heartbeat. Pressure changes on either side of the valves cause them to open their flap-like "doors" (called cusps or leaflets) at just the right time, then close tightly to prevent a backflow of blood.

There are 4 valves in the heart:

• Tricuspid valve
• Pulmonary valve
• Mitral valve
• Aortic valve

Nearly all of these operations are done to repair or replace the mitral or aortic valves. These valves are on the left side of the heart, which works harder than the right. They control the flow of oxygen-rich blood from the lungs to the rest of the body.

Valve Disease

If valve damage is mild, doctors may be able to treat it with medicines. If damage to the valve is severe, surgery to repair or replace the valve may be needed.

What is valve repair?

Valve repair can usually be done on congenital valve defects (defects you are born with) and has a good success record with treating mitral valve defects.

Here are some procedures surgeons may use to repair a valve:

• Commissurotomy, which is used for narrowed valves, where the leaflets are thickened and perhaps stuck together. The surgeon opens the valve by cutting the points where the leaflets meet.
• Valvuloplasty, which strengthens the leaflets to provide more support and to let the valve close tightly. This support comes from a ring-like device that surgeons attach around the outside of the valve opening.
• Reshaping, where the surgeon cuts out a section of a leaflet. Once the leaflet is sewn back together, the valve can close properly.
• Decalcification, which removes calcium buildup from the leaflets. Once the calcium is removed, the leaflets can close properly.
• Repair of structural support, which replaces or shortens the cords that give the valves support (these cords are called the chordae tendineae and the papillary muscles). When the cords are the right length, the valve can close properly.
• Patching, where the surgeon covers holes or tears in the leaflets with a tissue patch.

What is valve replacement?

Severe valve damage means that the valve will need to be replaced. Valve replacement is most often used to treat aortic valves and severely damaged mitral valves. It is also used to treat any valve disease that is life-threatening. Sometimes, more than one valve may be damaged in the heart, so patients may need more than one repair or replacement.

There are 2 kinds of valves used for valve replacement:

• Mechanical valves, which are usually made from materials such as plastic, carbon, or metal. Mechanical valves are strong, and they last a long time. Because blood tends to stick to mechanical valves and create blood clots, patients with these valves will need to take blood-thinning medicines for the rest of their lives.
• Biological valves, which are made from animal tissue (called a xenograft) or taken from the human tissue of a donated heart (called an allograft or homograft). Sometimes, a patient's own tissue can be used for valve replacement (called an autograft). Patients with biological valves usually do not need to take blood-thinning medicines. These valves are not as strong as mechanical valves, though, and they may need to be replaced every 10 years or so. Biological valves break down even faster in children and young adults, so these valves are used most often in elderly patients.

You and your doctor will decide which type of valve is best for you.

During valve repair or replacement surgery, the breastbone is divided, the heart is stopped, and blood is sent through a heart-lung machine. Because the heart or the aorta must be opened, heart valve surgery is open heart surgery.

What to Expect

The operation will usually be scheduled at a time that is best for you and your surgeon, except in urgent cases. As the date of your surgery gets closer, be sure to tell your surgeon and cardiologist about any changes in your health. If you have a cold or the flu, this can lead to infections that may affect your recovery. Be aware of fever, chills, coughing, or a runny nose. Tell the doctor if you have any of these symptoms.

Also, remind your cardiologist and surgeon about all of the medicines you are taking, especially any over-the-counter medicines such as aspirin or those that might contain aspirin. You should make a list of the medicines and bring it with you to the hospital.

It is always best to get complete instructions from your cardiologist and surgeon about the procedure, but here are some basics you can expect when you have valve repair or replacement surgery.

Before the Hospital Stay

Most patients are admitted to the hospital the day before surgery or, in some cases, on the morning of surgery.

The night before surgery, you will be asked to bathe to reduce the amount of germs on your skin. After you are admitted to the hospital, the area to be operated on will be washed, scrubbed with antiseptic, and, if needed, shaved.

A medicine (anesthetic) will make you sleep during the operation. This is called "anesthesia." Because anesthesia is safest on an empty stomach, you will be asked not to eat or drink after midnight the night before surgery. If you do eat or drink anything after midnight, it is important that you tell your anesthesiologist and surgeon.

If you smoke, you should stop at least 2 weeks before your surgery. Smoking before surgery can lead to problems with blood clotting and breathing.

Day of Surgery

Before surgery, you may have an electrocardiogram (ECG or EKG), blood tests, urine tests, and a chest x-ray to give your surgeon the latest information about your health. You will be given something to help you relax (a mild tranquilizer) before you are taken into the operating room.

Small metal disks called electrodes will be attached to your chest. These electrodes are connected to an electrocardiogram machine, which will monitor your heart's rhythm and electrical activity. You will receive a local anesthetic to numb the area where a plastic tube (called a line) will be inserted in an artery in your wrist. An intravenous (IV) line will be inserted in a vein. The IV line will be used to give you the anesthesia before and during the operation.

After you are completely asleep, a tube will be inserted down your windpipe and connected to a machine called a respirator, which will take over your breathing. Another tube will be inserted through your nose and down your throat, into your stomach. This tube will stop liquid and air from collecting in your stomach, so you will not feel sick and bloated when you wake up. A thin tube called a catheter will be inserted into your bladder to collect any urine produced during the operation.

A heart-lung machine is used for all valve repair or replacement surgeries. This will keep oxygen-rich blood flowing through your body while your heart is stopped. A perfusion technologist or blood-flow specialist operates the heart-lung machine. Before you are hooked up to this machine, a blood-thinning medicine called an anticoagulant will be given to prevent your blood from clotting. The surgical team is led by the cardiovascular surgeon and includes other assisting surgeons, an anesthesiologist, and surgical nurses.

After you are hooked up to the heart-lung machine, your heart is stopped and cooled. Next, a cut is made into the heart or aorta, depending on which valve is being repaired or replaced. Once the surgeon has finished the repair or replacement, the heart is then started again, and you are disconnected from the heart-lung machine.\

The surgery can take anywhere from 2 to 4 hours or more, depending on the number of valves that need to be repaired or replaced.

Recovery Time

You can expect to stay in the hospital for about a week, including at least 1 to 3 days in the Intensive Care Unit (ICU).

Recovery after valve surgery may take a long time, depending on how healthy you were before the operation. You will have to rest and limit your activities. Your doctor may want you to begin an exercise program or to join a cardiac rehabilitation program.

If you have an office job, you can usually go back to work in 4 to 6 weeks. Those who have more physically demanding jobs may need to wait longer.

Life after Valve Replacement

Most valve repair and replacement operations are successful. In some rare cases, a valve repair may fail and another operation may be needed.

Patients with a biological valve may need to have the valve replaced in 10 to 15 years. Mechanical valves may also fail, so patients should alert their doctor if they are having any symptoms of valve failure.

Patients with a mechanical valve will need to take a blood-thinning medicine for the rest of their lives. Because these medicines increase the risk of bleeding within the body, you should always wear a medical alert bracelet and tell your doctor or dentist that you are taking a blood-thinning medicine.

Even if you are not taking a blood-thinning medicine, you must always tell your doctor and dentist that you have had valve surgery. If you are having a surgical or dental procedure, you should take an antibiotic before the procedure. Bacteria can enter the bloodstream during these procedures. If bacteria get into a repaired or artificial valve, it can lead to a serious condition called bacterial endocarditis. Antibiotics can prevent bacterial endocarditis.

Patients with mechanical valves say they sometimes hear a quiet clicking sound in their chest. This is just the sound of the new valve opening and closing, and it is nothing to be worried about. In fact, it is a sign that the new valve is working the way it should.

Minimally Invasive ValveSurgery

Minimally invasive heart valve surgery is a technique that uses smaller incisions to repair or replace heart valves. This means there is less pain. Minimally invasive surgery also reduces the length of the hospital stay and the recovery time.

Minimally invasive valve surgery can only be done in certain patients. This type of surgery cannot be done in patients

• With severe valve damage
• Who need more than one valve repaired or replaced
• Who have clogged arteries (atherosclerosis)
• Who are obese

In some cases, minimally invasive valve surgery can be done using a robot. Robotic surgery does not require a large incision in the chest. It is not available at all hospitals, and patients with severe valve damage cannot have the procedure. The Texas Heart Institute has a robot.

With robotic surgery, the surgeon has a control console, a side cart with 3 robotic arms, a special vision system, and instruments. A computer translates the surgeon's natural hand and wrist movements made on the control console to instruments that have been placed inside the patient through small incisions. The robot's controls can read even the tiniest of movements the surgeon makes.

Robotic surgery can reduce the time it takes to do valve surgery, as well as shorten the hospital stay and recovery time. 

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WHAT IF HEART SURGERY DIDN'T LEAVE A HUGE SCAR? : Robotic Surgery (da Vinci Surgery)

If your doctor recommends surgery to treat mitral valve prolapse, you may be a candidate for da Vinci® Mitral Valve Repair, potentially the most effective least invasive treatment option available. da Vinci Mitral Valve Repair is an alternative to conventional open heart surgery – the traditional way to treat mitral valve disease. da Vinci Mitral Valve Repair is performed using the da Vinci Surgical System, enabling your surgeon to operate with unparalleled precision and control through a few small incisions.

In addition to avoiding the pain and trauma of sternotomy and rib spreading, da Vinci Mitral Valve Repair provides most patients with the following benefits over open surgery:

o    Less risk of infection

o    Less blood loss and need for blood transfusions

o    Shorter hospital stay

o    Significantly less pain and scarring

o    Faster recovery

o    Quicker return to normal activities

o    And a potentially better clinical outcome

OLD VS. NEW

While surgery is generally the most effective way to treat disorders of the heart, lungs and esophagus, traditional open surgery has a number of inherent drawbacks caused primarily by making a large incision, splitting of the breastbone and spreading the ribs to access the thoracic space. In addition to an 8 to 10” scar down the center of your chest, splitting of the breastbone leads to a lengthy recovery time as well as a prolonged delay before you will return to normal daily activities.

The minimally invasive da Vinci® Surgical System, provides surgeons and patients with what may be the most effective, least invasive treatment alternative for even the most complex cardiothoracic procedures such as mitral valve repair.

HEART VALVE DISEASE

HEART VALVES

Heart valves regulate the flow of blood through the heart's four chambers—two small, round upper chambers (atria) and two larger, cone-shaped lower chambers (ventricles). Each ventricle has a one-way inlet valve and a one-way outlet valve. In the right ventricle, the inlet valve is the tricuspid valve, which opens from the right atrium, and the outlet valve is the pulmonary (pulmonic) valve, which opens into the pulmonary arteries. In the left ventricle, the inlet valve is the mitral valve, which opens from the left atrium, and the outlet valve is the aortic valve, which opens into the aorta. Each valve consists of flaps (cusps or leaflets), which open and close like one-way swinging doors.

HEART VALVE DISORDERS

Heart valves don't always work as they should. A person can be born with an abnormal heart valve, a type of congenital heart defect.

A defective heart valve is one that fails to fully open or close. A stenotic heart valve can't open completely, so blood is pumped through a smaller-than-normal opening. A valve also may not be able to close completely. This leads to regurgitation (blood leaking back through the valve when it should be closed).

HEART VALVE TREATMENT IN INDIA

Most of the time, there are no (or few) symptoms for mitral valve conditions, and treatment is not needed. If you have severe mitral valve prolapse, you may need to stay in the hospital. Surgery to repair or replace the valve may be needed if you have severe mitral regurgitation or your symptoms get worse.

SURGERY

Surgery should be considered in virtually all patients with a leak that is graded as a 4 (severe) and in some patients with a leak that is graded as a 3 (moderately severe). When a patient with mitral valve regurgitation develops symptoms, a decrease in heart function, or an increase in heart size, surgery is recommended. Surgery should also be considered when a patient develops atrial fibrillation, which is an irregular heartbeat. Surgery is also recommended in many asymptomatic patients who have a severe leak.

MINIMALLY INVASIVE SURGERY

Recently, minimally invasive approaches to Mitral Valve Repair are replacing sternotomy as the surgical method of choice. Of the minimally invasive approaches, robotic surgery (da Vinci Surgery) has many practical advantages for both the patient and the surgeon – precision, fewer complications, reduced blood loss and shorter hospital stays.

Major Facts about Coarctation of the Aorta : Best Heart Surgery Hospital in India

Coarctation of the aorta is a birth defect in which a part of the aorta is narrower than usual.If the narrowing is severe enough and if it is not diagnosed, the baby may have serious problems and may need surgery or other procedures soon after birth. For this reason, coarctation of the aorta is often considered a critical congenital heart defect. The defect occurs when a baby’s aorta does not form correctly as the baby grows and develops during pregnancy. The narrowing of the aorta usually happens in the part of the blood vessel just after the arteries branch off to take blood to the head and arms, near the ductus arteriosus, although sometimes the narrowing occurs before or after the ductus arteriosus. In some babies with coarctation, it is thought that some tissue from the wall of ductus arteriosus blends into the tissue of the aorta. When the tissue tightens and allows the ductus arteriosus to close normally after birth, this extra tissue may also tighten and narrow the aorta.

The narrowing, or coarctation, blocks normal blood flow to the body. This can back up flow into the left ventricle of the heart, making the muscles in this ventricle work harder to get blood out of the heart. Since the narrowing of the aorta is usually located after arteries branch to the upper body, coarctation in this region can lead to normal or high blood pressure and pulsing of blood in the head and arms and low blood pressure and weak pulses in the legs and lower body.

If the condition is very severe, enough blood may not be able to get through to the lower body. The extra work on the heart can cause the walls of the heart to become thicker in order to pump harder. This eventually weakens the heart muscle. If the aorta is not widened, the heart may weaken enough that it leads to heart failure. Coarctation of the aorta often occurs with other congenital heart defects.

In a recent study in Atlanta, CDC has estimated that about 4 out of every 10,000 babies born have coarctation of the aorta 1.

Causes and Risk Factors

The causes of heart defects, including coarctation of the aorta, among most babies are unknown. Some babies have heart defects because of changes in their genes or chromosomes. Heart defects, like coarctation of the aorta, are also thought to be caused by a combination of genes and other risk factors, such as things the mother comes in contact with in the environment, what the mother eats or drinks, or medicines the mother uses.

Diagnosis

Coarctation of the aorta is usually diagnosed after the baby is born. How early in life the defect is diagnosed usually depends on how mild or severe the symptoms are.  Those with severe narrowing will have symptoms early in life, while babies with mild narrowing may never have problems, or signs may not be detected until later in life.

In babies with a more serious condition, early signs usually include:

• pale skin
• irritability
• heavy sweating
• difficulty breathing

Detection of the defect is often made during a physical exam. In infants and older individuals, the pulse will be noticeably weaker in the legs or groin than it is in the arms or neck, and a heart murmur—an abnormal whooshing sound caused by disrupted blood flow—may be heard through a doctor’s stethoscope. Older children and adults with coarctation of the aorta often have high blood pressure in the arms.

Once suspected, an echocardiogram is the most commonly used test to confirm the diagnosis. An echocardiogram is an ultrasound of the heart that can show problems with the structure of the heart and the blood flow through it, and how well the heart is working. It will show the location and severity of the coarctation and whether any other heart defects are present. Other tests to measure the function of the heart may be used including chest x-ray,electrocardiogram (EKG), magnetic resonance imaging (MRI), and cardiac catheterization.

Coarctation of the aorta is often considered a critical congenital heart defect (CCHD) because if the narrowing is severe enough and it is not diagnosed, the baby may have serious problems soon after birth. CCHDs also can be detected with newborn pulse oximetry screening. Pulse oximetry is a simple bedside test to determine the amount of oxygen in a baby’s blood. Low levels of oxygen in the blood can be a sign of a CCHD. Newborn screening using pulse oximetry can identify some infants with a CCHD, like coarctation of the aorta, before they show any symptoms.

Treatment

No matter what age the defect is diagnosed, the narrow aorta will need to be widened once symptoms are present. This can be done with surgery or a procedure called balloon angioplasty. A balloon angioplasty is a procedure that uses a thin, flexible tube, called a catheter, which is inserted into a blood vessel and directed to the aorta. When the catheter reaches the narrow area of the aorta, a balloon at the tip is inflated to expand the blood vessel. Sometimes a mesh-covered tube (stent) is inserted to keep the vessel open. The stent is used more often to initially widen the aorta or re-widen it if the aorta narrows again after surgery has been performed. During surgery to correct a coarctation, the narrow portion is removed and the aorta is reconstructed or patched to allow blood to flow normally through the aorta.

Even after surgery, children with a coarctation of the aorta often have high blood pressure that is treated with medicine. It is important for children and adults with coarctation of the aorta to follow up regularly with a cardiologist (a heart doctor) to monitor their progress and check for other health conditions that might develop as they get older.

What can I expect after Angioplasty and Stenting? : Best Heart Hospital in India

Am I a candidate for Angioplasty and Stenting?

You may be a candidate for angioplasty and stenting if you have moderate to severe narrowing or blockage in one or more of your blood vessels. Usually, you will also have symptoms of artery disease, such as pain or ulceration, in one of your limbs.

If you have extremely hard plaque deposits, blockages that contain blood clots or a large amount of calcium, extensive or particularly long blockages, blood vessel spasms that don't go away, or complete blockages that cannot be crossed with the catheter, you probably are not a good candidate for angioplasty.

Am I at risk for complications during Angioplasty and Stenting?

Complications to angioplasty and stenting may include reactions to the contrast dye, weakening of the artery wall, bleeding at the access puncture site in the vessel or the angioplasty site, re-blocking of the treated artery, and kidney problems. Additionally, blockages can develop in the arteries downstream from the plaque if plaque particles break free during the angioplasty procedure. If severe, these can lead to worsening of the blood flow.

If you have diabetes or kidney disease, you may have a higher risk of complications from the contrast dye, such as kidney failure. In the case of kidney disease, sometimes pre-treatment with medications or fluids may decrease the impact on your kidneys.

People with blood clotting disorders also may have a higher risk of complications from the procedure. If the plaque deposits in your arteries are especially long, you may have a greater chance of your artery closing up again after angioplasty and stenting.

What happens during Angioplasty and Stenting?

Your physician will usually insert the angioplasty catheter through a small puncture point over an artery in your groin, your wrist, or your elbow. Before the insertion, he or she will clean your skin and shave any hair in the immediate area. This is done to reduce your risk of infection. Your physician numbs your skin and then makes a small cut or puncture to reach the artery below. Although you may be given some mild sedation, your vascular surgeon will usually want you to stay reasonably alert to follow instructions and describe your sensations during the procedure.

Your vascular surgeon then inserts a guide wire or a guide catheter into your artery. Using a type of x ray that projects moving pictures on a screen, your physician guides the catheter through your blood vessels. Because you have no nerve endings in your arteries, you will not feel the catheters as they move through your body.

Next, your vascular surgeon will insert a balloon catheter over the guide wire or through the guide catheter. The balloon catheter carries a deflated and folded balloon on its tip. Your vascular surgeon guides the balloon catheter to the narrowed section of your artery. He or she partially inflates the balloon by sending fluid through the balloon catheter.

Your vascular surgeon watches the x ray screen for signs of a pinch in the balloon. Then, your vascular surgeon will inflate the balloon more, until the pinch caused by your artery flattens out. When the balloon is full, your vascular surgeon may deflate and re-inflate it repeatedly to press the plaque against your artery walls. Usually, this process takes a few minutes. Sometimes, if you have a severe blockage, your physician may need to inflate and deflate the balloon longer.

Your artery may stretch and your blood flow through the artery stops when the balloon is pushing your artery open. This may cause pain. However, the pain should go away when your vascular surgeon deflates the balloon and normal blood flow resumes. Make sure to tell your physician if you experience any symptoms during angioplasty.

There is a risk that your artery will re-narrow or become blocked again at the site where the balloon was inflated. This can happen soon after the procedure, or months to years later. Re-narrowing of your artery is called restenosis, and if your artery suddenly becomes blocked again it is called re-occlusion. Restenosis can happen when scar tissue builds up inside your arteries where the balloon compressed your plaque deposits.

After angioplasty, your vascular surgeon will sometimes need to use a stent to brace the artery open to prevent re-occlusion. A stent is a tiny mesh tube that looks like a small spring, and comes in a variety of sizes. To place a stent, your physician removes the angioplasty balloon catheter and inserts a new catheter. On this catheter, a closed stent surrounds a deflated balloon. Your vascular surgeon guides the stent through your blood vessels to the place where the angioplasty balloon widened your artery. Your physician inflates the balloon inside of the stent. This expands the stent. Your physician then deflates and removes the balloon. The stent remains in place to support the walls of your artery. Your artery walls grow over the stent, preventing it from moving. Although stents help prop open your arteries, scar tissue sometimes can eventually form around stents and cause restenosis.

A new type of stent is coated with drugs. These drugs may help prevent scar tissue from forming inside a stent. Studies have shown that these new stents may be more likely to prevent restenosis than ordinary, non-coated stents. In the United States, physicians currently use drug-coated stents in coronary arteries (the arteries supplying the heart). Experts are still testing drug-coated stents for use in other arteries.

Once your vascular surgeon finishes angioplasty and stenting, he or she removes all of the catheters from your body. If blood-thinning medications have been used, your physician may leave a short tube, called a sheath, in your artery for a short time until the medications have worn off sufficiently to allow the puncture site to seal over when the sheath is removed.

Eventually, your physician removes the sheath and presses on the puncture area for 15 to 30 minutes to prevent bleeding. Sometimes, instead of pressing, your physician may close the area with a device that functions like a tiny cork, or he or she may use stitches.

Angioplasty and stenting usually takes between 45 minutes and 3 hours, but sometimes longer depending upon the particular circumstances.

What can I expect after Angioplasty and Stenting?

Usually, you will stay in bed for six hours after your angioplasty. During this time, your vascular surgeon and the hospital staff closely monitor you for any complications. If your physician inserted the catheters through an artery in your groin, you may have to hold your leg straight for several hours. Similarly, if your arm was used, then you will need to hold it still to minimize the risk of bleeding.

If you notice any unusual symptoms after your procedure, you should tell your vascular surgeon immediately. These symptoms include leg pain that lingers or gets worse, a fever, shortness of breath, an arm or a leg that turns blue or feels cold, and problems around your access site, such as bleeding, swelling, pain, or numbness.

After you return home, your vascular surgeon will give you instructions about everyday tasks. For example, you should not lift more than about 10 pounds for the first few days after your procedure. You should drink plenty of water for 2 days to help flush the contrast dye out of your body. You can usually shower 24 hours after your procedure, but you should avoid baths for a few days.

Your physician may prescribe aspirin or other medications that thin your blood. These medications will help prevent clots from forming on your stent. Your physician may also ask you to follow an easy exercise program, like walking.

You will be asked to schedule a time to see your physician after the procedure. At this appointment, your physician may check your blood to make sure your medications are at the right dosage. He or she may also use tests to see how blood is flowing through your treated artery.

Are there any complications?

Serious complications are unusual following angioplasty and stenting but, nevertheless, can occur.

Less serious complications include bleeding or bruising where your vascular surgeon inserted the catheters. Sometimes, the hole created by the catheter does not completely close. This can create a false channel of blood flow. Rarely, an abnormal connection can form between an artery and a vein at the place where the catheter was inserted. These problems usually go away. However, if you have any serious symptoms, your vascular surgeon can treat you.

You may have an increased risk for blood clots forming along your stent, especially in the first month after your procedure. To reduce this risk, your physician may prescribe medications that thin your blood.

As more time passes after your angioplasty and stenting, restenosis becomes more likely. Stents, especially drug-coated stents, may reduce this risk. However, in some cases, you may need a repeat angioplasty or a bypass surgery if a restenosis develops.