Heart Stents

Yes, those with diabetes have a two to fourfold risk of developing Coronary Artery Disease (CAD) and the extent and severity of CAD depends on the duration of diabetes. Whether the extent of coronary disease will warrant a stent or other treatment depends on the results of the coronary angiogram.

NO – heart stents cannot be removed for any reason except in the extremely case of a stent getting infected (about 17 or so cases reported since 1986 when the first stent was implanted and of course millions of people have had stents since then). In which case heart surgery is necessary along with antibiotics but this is so rare that neither myself nor any of my colleagues over the years (almost 17 years) have seen an infected stent. Stents cannot be removed because they are essentially a wire mesh scaffold for the artery to heal onto.

Your father can rest assured that after a successful heart angioplasty he can look forward to a good quality of life and longevity provided that the coronary disease fits the criteria and the coronary angioplasty is technically sound and complete. Some simple rules to follow after the coronary angioplasty procedure are – ensure full compliance with the medication especially the blood thinning agents. Usually two blood thinning agents are given and these should be taken meticulously every day without fail.

Yes we do use devices occasionally to remove/shave/excise plaques but this is used in less than 5% of coronary angioplasties at present. The current devices licensed for plaque removal usage in the heart are called: Rotablator (a nickel plated brass burr with microscopic diamond crystals on it rotating at high speed) which excises the hard plaque tissue Excimer laser (which uses high energy light to dissolve plaque without harming healthy tissue) and Orbital atherectomy (which uses a diamond coated crown rotating at high speed to kind of “sand ” the calcium away).

The coronary angiogram is the current gold standard to establish the degree of coronary artery disease and with experience one can usually determine the stenosis with just “eyeballing”. However, I do use adjunct imaging inside the blood vessel itself, and this helps to clearly establish the area and character of the narrowing or stenosis in the coronary vessel. Evidence from trials clearly show that a narrowing is critical when it approaches 70% as it affects blood flow to the heart muscle.

Yes, 100% blocked arteries can be treated and many techniques exist nowadays. If the artery can be opened up through the normal route of blood flow it is called “antegrade” technique and there are newer specialized kits available for this technique. There are also techniques that have been developed in Japan over the years called “retrograde” technique which is a way of going through the blocked vessel in the reverse manner by approaching though other arteries.

I am afraid the evidence does point to the fact that there is a clear advantage both in terms of quality of life and mortality benefit (for instance in those patients who have a narrowing of more than 50% in the left main stem ie the major branch on the left side of the heart, only 50% will survive beyond three years on medical treatment alone). Of course mild to moderate narrowing in a small noncritical vessel will neither confer a survival advantage nor cause a dramatic change in your quality of life.

You need not worry about this aspect at all. When I do the procedure I always ensure there is adequate pain relief (they are big on pain relief in the UK and the cath lab sister would always be watching the patient intently and if the patient were to wince ever so slightly the pain medication was topped up immediately). At most you may feel some initial discomfort when the local anaesthetic is inserted. Following this the rest of the procedure should not cause any pain at all though the inflation of the balloon can cause transient pain (ie a bit like your angina pain) for about 30 seconds.

Let me give you a very brief overview of the development in the history of stents before coming to the practical aspects. In the 1960’s Dr Dotter described the conceptual aspect of angioplasty ie using a device like a catheter to dilate a narrowed artery. Dr Andreas Gruntzig in 1977 performed the first angioplasty procedure in an awake patient and in 1986, the first human coronary stent was inserted in France.

When a cardiologist is not able to insert a heart stent, this is usually due to: Either the artery being blocked for a long time (called a CTO or chronic total occlusion, usually with severe calcification) or Because the artery is very tortuous and the narrowing is in an area which is difficult to reach In the first instance, ie CTO, where the procedure has been unsuccessful - one could reattempt the procedure with further specialised equipment, and with experts who have specialised exclusively in opening up such arteries.