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Ravi, a 50-year-old accountant, collapsed outside his building while returning from a walk. He had been suffering from chest pain over the last month but had ignored it due to his busy schedule. He was rushed to the emergency department of a nearby hospital. Though he was non-diabetic and had no history of hypertension, he was a chronic smoker. His doctor suspected acute myocardial infarction (heart attack) and immediately conducted a 12-lead electrocardiogram. This was followed by coronary angiography which revealed a >90% stenosis or blockage in one of the coronary arteries. He underwent stenting with a drug-eluting stent (DES). He recovered well from the surgery and was advised antiplatelet therapy along with other medications.
Coronary artery disease (CAD) comprises heart diseases such as angina (chest pain), heart attacks and acute coronary syndrome which are caused due to narrowing or blockage of coronary arteries due to fatty deposits called plaque. It is a leading cause of death across the globe. Coronary angioplasty or percutaneous coronary intervention (PCI) is a non-surgical minimal invasive procedure with less than 0.5% complication rate. Percutaneous Transluminal Coronary Angioplasty or angioplasty is the preferred procedure used to open such blocked arteries in the heart. A thin tube called a catheter with a tiny balloon is inserted via the groin to reach the blocked area. The balloon is then expanded to help widen the blood vessel and restore the flow of blood and a small wire mesh called a stent is placed to keep the artery open and prevent its narrowing over time. The first angioplasty in India was performed in 1984.
Evolution of coronary angioplasty in cardiac care
The past several decades have witnessed a revolution in cardiovascular care with the introduction of percutaneous methodologies for the treatment of patients with coronary artery disorders. Stent placement is now the prevalent form of myocardial revascularisation, with millions of procedures performed globally every year. This procedure has been characterised by continued investigation, research and development in both imaging techniques and stent design.
Early interventions using balloon angioplasty alone resulted in nearly 20-50% of patients presenting with restenosis within a year, leading to an increase in repeat procedures. To overcome these challenges, stents were developed in the mid-1980s and became a major evolution in the percutaneous management of CAD. With these coronary stents, doctors were able to keep the artery patent or open for longer periods.
Bare-metal stents (BMS) were the first type of stents deployed and they reduced repeat procedures by nearly 33% compared to balloon angioplasty alone. However, restenosis remained an issue with BMS too due to neointimal hyperplasia within the stented segment. Almost 15% of patients treated with a BMS needed to undergo a procedure again due to in-stent restenosis (ISR).
Drug-eluting stents (DESs) became the next best choice for treatment. DESs are made of up the standard metallic stent coated with a polymer which releases an antiproliferative drug into the coronary wall for a long time after stent implantation. However, first-generation DESs still resulted in late stent thrombosis. Modern second and third-generation DESs were designed to tackle these limitations, offering improved durability, flexibility, and deliverability, while enhancing patient outcomes.
Angioplasty and stenting together have proved to be life-enhancing and sometimes a life-saving alternative for a lot of people suffering from CAD. For most patients undergoing PCI with stent placement, doctors recommend DESs. With the plethora of options available, the interventional cardiologist makes the choice based on the patient profile, the type of lesion and its location.
They can be differentiated based on the material that they are made of such as stainless steel, cobalt-based alloy, tantalum, nitinol, inert coating, active coating, or biodegradable. The stent design may also differ. It may be in the form of a mesh, coil, slotted tube, ring, multi-design, or custom design. Other characteristics like strut thickness, metal-to-artery ratio, degree of radiopacity, foreshortening, type of polymer or drug used, and recoil are also taken into account while planning a procedure. More recent stents include those which are polymer-free and even bioabsorbable.
Moreover, with the technological advancement in cardiac care, interventional tools like fractional flow reserve (FFR), Intravascular Ultrasound (IVUS) and intravascular optical coherence tomography (OCT) help doctors in choosing the right treatment path based on the patient’s profile. Some of these decisions include whether a patient needs a stent, the type of stent, its precise length/diameter and placement, and long-term good outcomes.
From balloon angioplasty to modern DESs, scientific innovations in CAD have come a long way.
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Views expressed above are the author's own.
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