INTRODUCTION

What is Angioplasty?

Angioplasty, also known as percutaneous transluminal angioplasty(PTA), is a procedure used

to open blocked or narrowed blood vessels. During angioplasty, a thin tube with a balloon at
the tip is inserted into the narrowed blood vessel. The balloon is then inflated to widen the
artery and improve blood flow.

Why is Angioplasty Needed?

Angioplasty is often needed to treat conditions such as coronary artery disease (CAD) and
peripheral artery disease (PAD). These conditions can lead to reduced blood flow to vital
organs and tissues, causing symptoms such as chest pain, shortness of breath, and leg pain
during physical activity.(1)

 Blocked Arteries
Blockages in the arteries can lead to serious health issues, including heart attack and stroke.

 Chest Pain
Angina, a common symptom of coronary artery disease, can be relieved with angioplasty.

 Improved Blood Flow

Angioplasty helps restore proper blood flow, reducing the risk of cardiovascular events.

Benefits of Angioplasty

Angioplasty offers several benefits, including immediate relief of symptoms and a reduced
risk of heart attack. It also helps improve overall heart function and can prevent the need for
more invasive treatments, such as bypass surgery.

 Immediate Symptom Relief

Patients often experience relief from chest pain and improved exercise tolerance soon after
the procedure.

 Reduced Risk of Complications

By opening blocked arteries, angioplasty lowers the risk of heart attacks and other
cardiovascular events.

 Improved Quality of Life

Patients report increased energy levels and a better ability to perform daily activities
after angioplasty.

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Types of Percutaneous Transluminal Coronary Angioplasty (PTCA)
1. Balloon angioplasty
2. Carotid artery angioplasty
3. Cerebral angioplasty
4. Coronary artery stent
5. Laser angioplasty
6. PTA of the Femoral Artery

Conditions Treated by angioplasty

Atherosclerosis
A progressive disease in which plaque builds up in the inner lining of an artery causing the
artery wall to become thickened and lose elasticity.

Coronary artery disease

Occurs when arteries in the heart narrow or become blocked; may cause angina, a heart
attack, or congestive heart failure. (1)

Angioplasty and Stenting

Roughly one-third of patients with CAD will undergo coronary angioplasty and stenting.
These procedures take place in a cardiac catheterization laboratory, using the same type of
catheter used for diagnostic coronary angiography(2). During balloon angioplasty, a balloon-
tipped catheter pushes plaque back against the arterial wall to allow for improved blood flow
in the artery. Another angioplasty technique involves devices that remove plaque from the
arteries by cutting it away. Coronary stenting often accompanies the angioplasty procedure.
Stents are small wire-mesh metal tubes that provide scaffolding to support the damaged
arterial wall , reducing the chance that the vessel will close again (after angioplasty.

Benefits of Angioplasty

Angioplasty offers several benefits, including immediate relief of symptoms and a reduced
risk of heart attack. It also helps improve overall heart function and can prevent the need for
more invasive treatments, such as bypass surgery.

Immediate Symptom Relief

Patients often experience relief from chest pain and improved exercise tolerance soon after
the procedure.

Reduced Risk of Complications

By opening blocked arteries, angioplasty lowers the risk of heart attacks and other
cardiovascular events.

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Improved Quality of Life

Patients report increased energy levels and a better ability to perform daily activities after
angioplasty.

How is Angioplasty Performed?

During angioplasty, the patient is awake but sedated. The doctor makes a small incision in the
arm or leg and threads a thin tube (catheter) through the artery to the site of the blockage. A
small balloon at the end of the catheter is inflated to widen the artery, often followed by
placement of a stent to keep the artery open.

Risks and Complications of Angioplasty

While angioplasty is generally safe, it carries a small risk of complications. These may
include bleeding at the insertion site, damage to blood vessels, and allergic reactions to the
contrast dye.

Complication Description Incidence

Bleeding May occur at the catheter insertion site Low
Blood Vessel Damage Possible injury to arteries or veins during the procedure Rare
Allergic Reaction Response to contrast dye used in the procedure Very low

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1-BALLOON ANGIOPLASTY

FIGURE-1
Balloon angioplasty and stenting. A balloon-tipped catheter is positioned in the coronary artery
narrowing and inflated (A). The stent is positioned at the site of the coronary narrowing (B). When the
balloon is inflated, the stent expands and presses against the arterial wall (C). The balloon is deflated
and removed. The stent remains permanently in place, helping to keep the artery open (D). Within a
few weeks, new tissue will grow over the stent struts and cover it.

Nearly one million balloon angioplasty procedures are performed each year in the United
States alone.. Balloon angioplasty takes 1 to 2 hours to complete and is done with local
anesthesia on patients who are mildly sedated. Blood thinners, called glycoprotein IIb/IIIa
inhibitors, may be used intravenously during the angioplasty to prevent intracoronary blood
clotting. Most patients will stay overnight in the hospital for observation, will be discharged

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the following morning, and can resume normal activities within a week. Patients who receive
a coronary stent will be treated with a blood thinner (typically clopidogrel) for 1 month in
addition to long-term aspirin to prevent a blood clot from developing on the stent.
balloon Some patients have coronary plaques that are not amenable to balloon angioplasty or
stenting because 1) the coronary artery is too small or 2) there is a complete blockage that
cannot be crossed with the stent. (2)

A total of 520 patients with stable angina and a single coronary-artery lesion were randomly
assigned to either stent implantation (262 patients) or standard balloon angioplasty (258
patients). The primary clinical end points were death, the occurrence of a cerebrovascular
accident, myocardial infarction, the need for coronary-artery bypass surgery, or a second
percutaneous intervention involving the previously treated lesion, either at the time of the
initial procedure or during the subsequent seven months. The primary angiographic end point
was the minimal luminal diameter at follow-up, as determined by quantitative coronary
angiography. (3)
After exclusions, 52 patients in the stent group (20 %) and 76 patients in the angioplasty
group (30%) reached a primary clinical end point (relative risk, 0.68; 95 % confidence
interval, 0.50 to 0.92; P = 0.02). The difference in clinical-event rates was explained mainly
by a reduced need for a second coronary angioplasty in the stent group (relative risk, 0.58; 95
% confidence interval, 0.40 to 0.85; P = 0.005). The mean (±SD) minimal luminal diameters
immediately after the procedure were 2.48 ±0.39 mm in the stent group and 2.05 ±0.33 mm
in the angioplasty group; at follow-up, the diameters were 1.82 ±0.64 mm in the stent group
and 1.73 ±0.55 mm in the angioplasty group (P = 0.09), which correspond to rates of
restenosis (diameter of stenosis, ≥ 50 %) of 22 and 32 %, respectively (P = 0.02). Peripheral
vascular complications necessitating surgery, blood transfusion, or both were more frequent
after stenting than after balloon angioplasty (3). The mean hospital stay was significantly
longer in the stent group than in the angioplasty group (8.5 & 3.1 days).

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2. CAROTID ARTERY ANGIOPLASTY

Carotid angioplasty and stenting is the procedure in which we open clogged arteries to restore

blood flow to the brain. They're often performed to treat or prevent strokes.

The carotid arteries are located on each side of your neck. These are the

main arteries that supply blood to your brain. They can be clogged with fatty deposits

(plaque) that slow or block blood flow to the brain — a condition known as carotid artery

disease — which can lead to a stroke.

The procedure involves temporarily inserting and inflating a

tiny balloon into the clogged artery to widen the area so that blood can flow freely to your

brain. Carotid angioplasty is often combined with another procedure called stenting. Stenting

involves placing a small metal coil (stent) in the clogged artery (4). The stent helps prop the

artery open and decreases the chance of it narrowing again. Carotid angioplasty and stenting

may be used when traditional carotid surgery (carotid endarterectomy) isn't possible, or it's

too risky.

FIG 2- Carotid artery angioplasty

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 FIG 3-Carotid endarterectomy

RISKS
With any medical procedure, complications might happen. Here are some of the possible
complications of carotid angioplasty and stenting:

 Stroke or ministroke (transient ischemic attack, or TIA). During angioplasty, blood

clots that may form can break loose and travel to your brain. You'll receive blood
thinners during the procedure to reduce this risk.
A stroke can also occur if plaque in your artery is dislodged when the catheters are
being threaded through the blood vessels.

 New narrowing of the carotid artery (restenosis). A major drawback of carotid

angioplasty is the chance that your artery will narrow again within months of the
procedure. Special drug-coated stents have been developed to reduce the risk of
restenosis. Medications are prescribed after the procedure to decrease the risk of
restenosis.
 Blood clots. Blood clots can form within stents even weeks or months after angioplasty.
These clots may cause a stroke or death. It's important to take aspirin, clopidogrel
(Plavix) and other medications exactly as prescribed to decrease the chance of clots
forming in your stent.
 Bleeding. You may have bleeding at the site in your groin or wrist where catheters were
inserted. Usually this may cause a bruise, but sometimes serious bleeding occurs and
may require a blood transfusion or surgical procedures.(5)

INDICATIONS
CAS is a reasonable alternative to CEA in select patients with high-grade asymptomatic
(more than 70%) or symptomatic carotid artery stenosis. Indications for CAS include high
surgical patient risk, such as severe pulmonary disease, recent myocardial infarction, unstable
angina, or severe congestive heart failure; a history of prior neck radiation that is anticipated
to make open surgical dissection difficult; a history of damage to contralateral vocal cords;

7
the presence of a tracheostomy, contralateral carotid occlusion; and previous CEA with
recurrent stenosis.

CONTRAINDICATIONS
The main contraindication to CAS via a transfemoral approach is unfavorable aortic arch
anatomy. This can include a heavily calcified aortic arch or a type 3 aortic arch. A relative
contraindication can be a history of severe allergic reaction to intravenous contrast dye.
However, patients can be pre-medicated to mitigate some of this risk. For a transcarotid
approach, a common carotid artery length of less than 5 cm from the clavicle is considered
inadequate.

3. Cerebral Angioplasty
If you are diagnosed with a blood clot to the brain that could lead to a stroke, you may require
a cerebral angioplasty and stent placement. (6) Your neurosurgeon will insert a catheter (a
thin tube) through a blood vessel in your leg or arm to open the blocked artery or vein in your
neck or brain. The neurosurgeon may also need to place a stent (a fine wire mesh tube) at the
site of the clot to keep the blood vessel open.

Cerebral angioplasty is similar to a widely used cardiology procedure and is used to open
partially blocked vertebral and carotid arteries in the neck, as well as blood vessels within the
brain.

FIG-4

FIG-5

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Stenting of carotid or vertebral arteries and large cerebral veins involves use of a fine, tubular
wire mesh to hold the vessel open.
Case report of Cerebral Angioplasty
A 72-year-old man underwent cerebral angioplasty and stenting for a high-grade eccentric
atherosclerotic stenosis (93%) of the right intracranial vertebral artery. The lesion was
sufficiently and smoothly dilated very easily with the use of a highly flexible, balloon-
expandable coronary stent. No complications occurred during or after the procedure. This
therapeutic option may prove to be a safe and useful means to resolve an intracranial
atherosclerotic stenosis.

For some time, metallic stents have been used in the coronary and other peripheral vessels
with a remarkable reduction in procedural morbidity, whereas it has only been in the past few
years that percutaneous transluminal cerebral balloon angioplasty (PTCBA) of the
intracranial artery has been reported. Although some studies have produced good results.
Others have described a high morbidity or mortality rate after intracranial PTCBA. We
describe a case in which elective cerebral angioplasty and stenting (CAS) resolved a high-
grade atherosclerotic eccentric stenosis of the intracranial vertebral artery very easily and
without complications. (7)

A 72-year-old man with an unruptured aneurysm in the right middle cerebral artery and total
occlusion of the left vertebral artery was referred to our institution for endovascular treatment
of a high-grade (93% diameter, 4.5-mm length) eccentric stenosis of the right intracranial
vertebral artery (Fig). Although it was hoped that the aneurysm could be surgically clipped,
the intracranial high-grade stenosis and total occlusion in the posterior cerebral circulation
indicated too great a risk for general anesthesia. Therefore, vascular reconstruction of the
intracranial stenosis, if possible under local anesthesia, was indicated to reduce the risk.

.
FIG-6

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72-year-old man with an unruptured aneurysm in the right middle cerebral artery and total occlusion of the
left vertebral artery.
A, Lateral view of the right vertebral arteriogram before stenting reveals a high-grade eccentric stenosis
(arrow) with 93% stenosis and 4.5-mm length. Scale bar: 10 mm.
B, Anteroposterior view of the right vertebral arteriogram before stenting.
C, Illustration shows the stainless steel stent, which was implanted in the intracranial vertebral artery. This
stent measures 12 mm in length and can be expanded to up to 4 mm in diameter.
D and E, Right vertebral arteriograms (D, lateral view; E, anteroposterior view) after stenting show smooth
and sufficient dilatation of the lesion and no residual stenosis (arrows).

4. Coronary Angioplasty
Coronary angioplasty is sometimes known as percutaneous transluminal coronary angioplasty
(PTCA). The combination of coronary angioplasty with stenting is usually referred to as
percutaneous coronary intervention (PCI).

When a coronary angioplasty is used

 Like all organs in the body, the heart needs a constant supply of blood. This is
supplied by the coronary arteries.
 In some people, these arteries can become narrowed and hardened (known
as atherosclerosis), which can cause coronary heart disease.
 If the flow of blood to the heart becomes restricted, it can lead to chest pain known
as angina, which is usually triggered by physical activity or stress.
 While angina can often be treated with medication, a coronary angioplasty may be
required to restore the blood supply to the heart in severe cases where medication is
ineffective.
 Coronary angioplasties are also often used as an emergency treatment after a heart
attack.

Angioplasty and stent placement

Angioplasty is the process of opening an artery by inflating a balloon. A stent is a mesh coil
that helps hold the artery open. Most stents slowly release a medicine that prevents the artery
from re-narrowing.
During angioplasty and stenting, flexible tubes called catheters and a balloon are used to
reopen a blocked artery. A catheter with an uninflated balloon on the tip is guided to the
blocked artery. The balloon inflates, widening the artery. The balloon is deflated and
removed. A stent is placed at the narrowed part to help keep the artery open.
If there's more than one blockage, the process may be repeated.
You might feel pressure in the area where the catheter is inserted. You also may feel some
mild discomfort when the balloon is inflated. (8)
Your healthcare team tells you how long the procedure is expected to take. The procedure
and recovery typically takes several hours.

Before the procedure

Sticky patches called electrodes are placed on your chest to check your heartbeat. Your blood
pressure also is checked. Your heart rate, pulse, blood pressure and oxygen level are
continuously checked before, during and after the procedure.

A member of your healthcare team may shave any hair from the body area where a flexible
tube called a catheter will be inserted.

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During the procedure

FIG-7

Coronary angioplasty and stenting is usually done in the hospital in a room with special
X-ray and imaging machines.

A healthcare professional inserts an IV into your arm or hand. You get medicines to help you
relax. The amount of sedation needed for coronary angioplasty and stenting depends on your
health conditions and why you're having the procedure. Usually you are awake during
angioplasty. But some people may need a combinations of medicines that puts them to sleep
during the procedure. This is called general anesthesia.

Fluids and other medicines, such as blood thinners, also are given through the IV.

The area where the catheter goes is numbed. Then, the doctor makes a small cut to reach the
blood vessel. The catheter is inserted into the blood vessel and guided to the heart.

Dye flows through the catheter. The dye helps blood vessels show up more clearly on the
X-ray images. Doing this helps the doctor check for blockages in the heart arteries. The
results help your doctor decide whether to continue with the angioplasty.

11
After the procedure

How long you stay in the hospital after angioplasty and stenting depends on why the
procedure was done.

When you return home, rest and drink plenty of fluids to help remove the imaging dye from
your body. You can expect the following after coronary angioplasty and stenting:

 Blood-thinning medicines. After getting a stent, you may need to take medicines to
prevent blood clots. Your doctor may recommend taking aspirin with another medicine,
such as clopidogrel (Plavix), ticagrelor (Brilinta) or prasugrel (Effient). Aspirin
recommendations vary. Check with your healthcare team before starting aspirin.
 Activity restrictions. Do not do strenuous exercise or lift heavy objects for at least 24
hours after coronary angioplasty and stenting. Ask your healthcare team if you have any
other activity restrictions.
 Cardiac rehabilitation. Your heart doctor may suggest a personalized program of
exercise and education called cardiac rehabilitation. It typically involves exercise
training, emotional support and education about a heart-healthy lifestyle. The
supervised program is designed to improve health in those with heart disease. It's often
recommended after a heart attack or heart surgery.
After coronary angioplasty and stenting, it's important to watch for complications. Call your
healthcare provider's office or hospital staff immediately if you have:

 Chest pain or shortness of breath.

 Weakness or fainting.
 Bleeding or swelling at the body area where the catheter was placed.
 Pain or discomfort at or below the catheter site. For example, pain in the hand if the
catheter went into a blood vessel in the arm.
 Signs of infection, such as redness, swelling, drainage or fever.
 A change in temperature or color of the leg or arm that was used for the procedure.
You will have follow-up appointments to check your heart health as you recover. During
these checkups, blood and imaging tests may be done to see how well your heart is working.

OUTCOME OF CORONARY ANGIOPLASTY

Coronary angioplasty and stent placement can greatly increase blood flow through a
previously blocked or narrowed heart artery. Your doctor can compare images of your heart
taken before and after the procedure to determine how well the angioplasty and stenting has
worked.

Angioplasty with stenting does not treat the underlying causes of blockages in your arteries.
To keep your heart healthy after angioplasty, try these tips:

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  Do not smoke or use tobacco.
 Eat a diet that is low in saturated fats and rich in vegetables, fruits, whole grains, and
healthy oils such as olive oil or avocado.
 Maintain a healthy weight. Ask a healthcare professional what a healthy weight is for
you.
 Get regular exercise.
 Control cholesterol, blood pressure and blood sugar.

ALTERNATIVES OF CORONARY ANGIOPLASTY

If many coronary arteries have become blocked and narrowed, or the structure of your
arteries is abnormal, a coronary artery bypass graft may be considered.

This is a type of invasive surgery where sections of healthy blood vessel are taken from other
parts of the body and attached to the coronary arteries. Blood is diverted through these
vessels, so it bypasses the narrowed or clogged parts of the arteries.

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ALTERNATIVE METHOD – CORONARY ARTERY BYPASS GRAFT
A coronary artery bypass graft (CABG) is a surgical procedure used to treat coronary heart
disease.

It diverts blood around narrowed or clogged parts of the major arteries to improve blood flow
and oxygen supply to the heart.

Why it's carried out

Like all organs in the body, the heart needs a constant supply of blood.

This is supplied by 2 large blood vessels called the left and right coronary arteries.

Over time, these arteries can become narrowed and hardened by the build-up of fatty deposits called
plaques.

This process is known as atherosclerosis.

People with atherosclerosis of the coronary arteries are said to have coronary heart disease.

Your chances of developing coronary heart disease increase with age. (9)

You're also much more likely to be affected if:

 you smoke
 you're overweight or obese
 you have a high-fat diet

Coronary heart disease can cause angina, which is chest pain that happens when the supply of
oxygen-rich blood to the heart becomes restricted.

While angina can often be treated with medicine, severe angina may require a coronary artery
bypass graft to improve the blood supply to the heart.

Another risk associated with coronary heart disease is the possibility of one of the plaques in
the coronary artery rupturing (splitting), creating a blood clot.

If the blood clot blocks the blood supply to the heart, it can trigger a heart attack.

A coronary artery bypass graft may be recommended to reduce your chances of having a
heart attack.

The procedure
A coronary artery bypass graft involves taking a blood vessel from another part of the body
(usually the chest, leg or arm) and attaching it to the coronary artery above and below the
narrowed area or blockage.

14
This new blood vessel is known as a graft. The number of grafts needed will depend on how
severe your coronary heart disease is and how many of the coronary blood vessels are
narrowed.

A coronary artery bypass graft is carried out under general anaesthetic, which means you'll be
unconscious during the operation. It usually takes between 3 and 6 hours.

FIG-8- GRAFTING

Recovery
Most people will need to stay in hospital for about 6 to 8 days after having a coronary artery
bypass graft.

You should have a follow-up appointment, typically about 6 to 8 weeks after your operation.

Recovering takes time and everyone recovers at slightly different speeds.

Generally, you should be able to sit in a chair after 1 day, walk after 3 days, and walk up and
down stairs after 5 or 6 days.

When you go home, you'll need to take things easy for a few weeks.

You should be able to return to most of your normal activities after about 6 weeks, including
working, driving and having sex. If you have a heavy manual job, you may need to stay off
work longer.

15
Most people make a full recovery within 12 weeks.

Risks of surgery
As with all types of surgery, a coronary artery bypass graft carries a risk of complications.

These are usually relatively minor and treatable, such as an irregular heartbeat or a wound
infection, but there's also a risk of serious complications, such as a stroke or heart attack.

After surgery
After having a coronary artery bypass graft, most people will experience a significant
improvement in symptoms such as breathlessness and chest pain, and their heart attack risk
will be lowered.

But a coronary artery bypass graft isn't a cure for coronary heart disease.

If you don't make lifestyle changes, such as eating a healthy diet and exercising regularly,
your grafted arteries will also eventually become hardened and narrowed.

5-Laser Angioplasty

A laser is used to "vaporize" the blockage in the artery.

Laser Angioplasty (also known as excimer laser coronary angioplasty) is a technique that
can be used to open coronary arteries blocked by plaque. A catheter with a laser at its tip is
inserted into an artery. Then it’s advanced through the artery to the blockage. When the laser
is in position, it emits pulsating beams of light that vaporize the plaque.

Laser coronary angioplasty was introduced in the early 1980s, mainly to manage balloon-
untreatable coronary artery lesions. However, due to the huge cost of the laser system,
disappointing results, and complications associated with the continuous waveform of argon
and Nd: YAG lasers available at that time, it did not gain popularity. Later in that decade,
excimer lasers were developed. Excimer, an acronym for the excited dimer, produces
ultraviolet laser energy pulsatile and short wavelength. (10) The pulsatile nature ensured the
precise ablation of plaque tissue with insignificant thermal injury to the vessel. The short
wavelength through less depth of penetration, compared to the infra-red range of argon and
Nd: YAG lasers, also limited collateral damage. Both of these properties of excimer lasers, in
addition to improvement in catheter design, proper selection of patients, and development of

16
safety protocols, played a crucial role in the reintroduction of laser technology in routine
practice. In 1988, the first successful excimer laser coronary angioplasty (ELCA) was
performed on a human subject at the Cedar Sinai Medical Center, Los Angeles.

FIG-9-Laser angioplasty

FIG-10-Eximer Laser

ANATOMY AND PHYSIOLOGY

Light amplification by stimulated emission of radiation, or LASER, in short, refers to the
creation of high-energy, single-wavelength light beam from a gas mixture. For excimer lasers
specifically, a mixture of xenon gas and diluted hydrogen chloride solution is used. After a
high-voltage electrical discharge is passed through this gas mixture, excited dimers
or excimers, xenon chloride (XeCl), are produced. These dimer molecules subsequently
release photons with an ultraviolet (UV) wavelength. Mirror systems are then utilized to
amplify this process and deliver the resulting high-energy laser beam to target tissues. On
contact with tissue, this laser beam then modifies it via three major mechanisms, as detailed
below:
1. Photochemical: Breakage of molecular bonds.
2. Photothermal: Vibration of molecular bonds generates heat and leads to the
vaporization of intracellular water, causing bubble formation. This ultimately leads to
cell rupture.
3. Photokinetic/photomechanical: The vapor bubbles generated secondary to the
photothermal mechanism coalesce to form larger bubbles, further breaking down
plaque tissue.

17
The breakdown products generated from these biochemical processes are small enough
(usually < 10 µm) to be rapidly cleared by the reticuloendothelial system of the body, hence
preventing distal embolization.

COMPLICATIONS
With the optimization of laser catheters and the introduction of safety techniques such as the
saline infusion protocol, the incidence of previously seen serious complications such as flow-
limiting dissections and vessel perforations has significantly decreased (10). Other measures
that can prevent these adverse outcomes include avoiding excessive force and lasing on high
settings for prolonged periods. Perforations are more likely to occur if an inappropriate size
or type of catheter is used (for example, concentric for an eccentrically located lesion), or if
energy is applied to a previously dissected segment .If any of these complications occur, the
lasing procedure should be aborted, and the complication managed per standard protocol.

TECHNIQUE OR TREATMENT
A standard 0.014-inch PCI guidewire is typically advanced till it crosses the target lesion,
after which the catheter is passed over it till its tip is in direct contact with the lesion. This is a
major advantage of excimer laser coronary angioplasty (ELCA) over other atherectomy
techniques, which usually require dedicated guidewires. The desired fluence, pulse rate, and
pulse width settings are then selected. By default, the system calibrates at 45 mJ/mm^2 at 25
Hz, with a pulse width of 135 ns. If resistance is encountered with these default settings, they
can be increased in a stepwise fashion. This should be undertaken slowly since higher
energies and frequencies can be associated with a higher chance of dissection and perforation
complications. The manufacturer recommends that fluence be increased first rather than the
frequency.

A saline flush protocol is then employed before initiation of lasing. (11) The concept behind
this step is that both blood and contrast media consist of macromolecules, including proteins,
that can absorb the bulk of the laser energy and lead to the formation of insoluble gas
bubbles. This also increases the risk of complications such as intimal dissection and
perforation. On the other hand, Saline provides a clear interface for the laser energy to be
delivered directly to the target lesion. To perform the saline flush protocol, a 1 L bag of 0.9%
normal saline is attached to one of the triple manifold ports via a three-way stopcock. The
contrast syringe is replaced with a clean 20 cc syringe used for flushing contrast and blood
from the entire system. Thereafter, the operator infuses a 5 to 10 cc bolus of normal saline
through the guiding catheter, with the initiation of lasing immediately afterward. This is
accompanied by a continuous infusion of normal saline at 1 to 3 mL/s throughout the
duration of laser activation. The system is programmed to activate for 5 to 10 seconds, after
which goes into a 5 to 10 second rest period. An audible alert will mark the end of this rest
period, at which point the next lasing sequence can be commenced. This potentially helps
avoid complications from prolonged laser energy exposure to the vessel.

It is also recommended that the catheter be advanced at a slow rate (<1 mm/s) within the
vessel lumen to allow the plaque tissue sufficient time to adequately absorb the light energy
and result in optimal vaporization and debulking.

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PTA of the Femoral Artery
An angioplasty is a procedure we use to restore blood flow through your arteries. A
percutaneous transluminal angioplasty (PTA) of the femoral artery is a minimally invasive
Your femoral artery is a large artery in your thigh and is the main blood supplier to the lower
body. type of angioplasty, restoring blood flow to your femoral artery.
Traditionally, if the femoral artery was blocked or narrowed, we needed to perform an open
vascular surgery. However, we can now perform this procedure using a minimally invasive
approach, without making a large incision. The procedure, called percutaneous transluminal
angioplasty, opens the blocked or narrowed femoral artery.(13)

FIG-11 FEMORAL ARTERY

OUTCOME OF PTA OF FEMORAL ARTERY

Procedural success was achieved in 96% of cases. At a mean follow-up of 24 months (with 1
patient lost of follow-up), the absence of binary restenosis was 92.5%. At the end of follow-
up, 82% of patients continued to show clinical improvement. Freedom from TLR was 97%.
Stent fracture rate at 1 year was 9%.(12)

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CONCLUSION
PTA of the CFA and its bifurcation is a reliable technique with good midterm functional
results. These results justify performing a randomized study comparing surgery and
endovascular treatment. (12).

Future Directions of Angioplasty

PTCA, with the use of balloon angioplasty and stent placement, has revolutionized the
treatment of coronary artery disease. Ongoing research focuses on improving stent designs,
reducing the need for long-term medication, and enhancing patient outcomes, laying the
foundation for future advancements in cardiac care.

ONGOING INNOVATIIONS
The advances in percutaneous coronary intervention (PCI) have been, above all, dependent
on the work of pioneers in surgery, radiology, and interventional cardiology. From Grüntzig's
first balloon angioplasty, PCI has expanded through technology development, improved
protocols, and dissemination of best-practice techniques. We can nowadays treat more
complex lesions in higher-risk patients with favourable results. Guide wires, balloon types
and profiles, debulking techniques such as atherectomy or lithotripsy, stents, and scaffolds all
represent evolutions that have allowed us to tackle complex lesions such as an unprotected
left main coronary artery, complex bifurcations, or chronic total occlusions. Best-practice
PCI, including physiology assessment, imaging, and optimal lesion preparation are now the
gold standard when performing PCI for sound indications, and new technologies such as
intravascular lithotripsy for lesion preparation, or artificial intelligence, are innovations in the
steps of 4 decades of pioneers to improve patient care in interventional cardiology. In the
present review, major innovations in PCI since the first balloon angioplasty and also
uncertainties and obstacles inherent to such medical advances are described.

3D angioplasty procedure
3D angioplasty to be a game-changer for coronary artery disease patients. Here's who is a
good candidate; benefits of this treatment to avoid bypass surgery

Advancements in medical technology have propelled the field of cardiology to new heights,
offering heart patients alternatives to traditional bypass surgeries and one such revolutionary
procedure is 3D angioplasty, which promises to be a game-changer for those suffering from
coronary artery disease. Unlike conventional methods that involve using stents to open
narrow or blocked blood vessels, this cutting-edge technique combines real-time imaging and
computer-generated models to navigate through intricate networks.

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. By providing doctors with precise information about the size and location of blockages, 3D
angioplasty not only minimises procedural complications but also ensures better outcomes for
patients.(14)

3D angioplasty or imaging-guided angioplasty is done with a light-based approach called

Optical coherence tomography (OCT) or a sound-based approach which is like an optical
analog of intravascular ultrasound (IVUS) that can be used to examine the coronary arteries
and vessel wall. The doctor by doing so will get information from the inside rather than just
pushing a luminogram to get an idea about the calcification and percentage of the stenosis.
Apart from that, the treating doctor will also understand the inflammation and swelling or
thrombus, length of involvement and the diameters.

FIG 12-3D Angioplasty

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REFRENCES
1-https://stanfordhealthcare.org/medical-treatments/a/angioplasty.html

accessed on 30-10-2023

2-Andrew D. Michaels and Kanu Chatterjee, Angioplasty Versus Bypass Surgery for
Coronary Artery Disease Originally published3 Dec2002 Circulation. 2002;106:e187–e190
3- Patrick W. Serruys, Peter de Jaegere,et al., for the Benestent Study Group, A Comparison
of Balloon-Expandable-Stent Implantation with Balloon Angioplasty in Patients with
Coronary Artery Disease, August 25, 1994.

4-N Engl J Med 1994; 331:489-4954- https://www.mayoclinic.org/tests-procedures/carotid-

angioplasty-and-stenting/about/pac-20385111

5- Taimur Saleem1; Donald T. Baril ; Carotid artery stenting, july24-2023

6-https://stanfordhealthcare.org/medical-treatments/a/angioplasty/types/cerebral-
angioplasty.html

7-Takahisa Mori, Ken Kazita and Koreaki Mori , Cerebral Angioplasty and Stenting for
Intracranial Vertebral Atherosclerotic Stenosis, American Journal of Neuroradiology May
1999, 20 (5) 787-789

8- https://www.nhs.uk/conditions/coronary-angioplasty/recovery/

9- https://www.nhs.uk/conditions/coronary

10- Uzair A. Mahmood; Georges Hajj, Excimer Laser Coronary Angioplasty,NIH July 24,
2023.
11- Egred M, Brilakis ES. Excimer Laser Coronary Angioplasty (ELCA): Fundamentals, Mechanism
of Action, and Clinical Applications. J Invasive Cardiol. 2020 Feb;32(2):E27-E35.

12-Pierre-Olivier Thiney , Antoine Millon , Tarek Boudjelit , Nellie Della Schiava , Patrick
Feugier , Patrick Lermusiaux Angioplasty of the common femoral artery and its bifurcation
PMID: 25765633 DOI: 10.1016/j.avsg.2015.02.001

13-https://stanfordhealthcare.org/medical-treatments/p/percutaneous-transluminal-angioplasty-
femoral artery.

14- Zarafshan Shiraz ,3D angioplasty procedure: Benefits of this new treatment to avoid
bypass surgery

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