Angioplasty and Stent Education Guide

Table of Contents

Treatingcoronaryarterydisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Whatiscoronaryarterydisease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Coronaryarterydiseasetreatmentoptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Whatarecoronaryarterystents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Whatarethedifferenttypesofcoronary stents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Howdoesthedrugcoatingandpolymerworkonadrug-elutingstent . . . . . . . . . . 8

Risksoftreatmentoptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Beforeyourcoronaryarterystentingprocedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Duringatypicalcoronaryarterystentingprocedure . . . . . . . . . . . . . . . . . . . . . . . . 12

Afteratypicalcoronaryarterystentingprocedure . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Frequentlyaskedquestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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Treating coronary artery disease

Yourdoctormaywantyoutohaveastentplacedinyourcoronary

artery .Thisistohelptreatyourcoronaryarterydisease .Thisguide

explainstheprocedureandwhatyoucanexpectfromstarttofinish .

Aglossaryattheendofthisguidedefinescommonmedicalterms

aboutthisprocedure .

Youwillalsolearnstepsyoucantaketoliveahealthierlifewith

coronaryarterydisease .

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Coronary Artery Disease (CAD)isthenarrowingofthearteriesintheheart .Thisnarrowingcanalsobecalledstenosis .Itisusuallycausedbyabuildupoffatorcalciumdepositscalledplaque .Overtime,thisplaquecanbuildtoatotalblockageoftheartery .Thisprocessiscalledatherosclerosis .

Whentheheartdoesn’treceiveenoughbloodflowduetoblockageintheartery,itmaycausemildtoseverechestpainorpressure .Thispainorpressurecanalsospreadtothearmsorjaw .Ifthearteriesarecompletelyblocked,itcanresultinaheartattack .Anyonewhoexperiencessymptomsshouldpromptlycall911 .Morethan13millionAmericanssufferfromCADeachyear .However,thetreatmentofCADhaschangedinrecentyears,andmanyCADpatientsareabletoreturntoanormallifestyleshortlyaftertreatment .

Who is at risk?Ifyouhaveahistoryofhighcholesterol,diabetes,smoking,highbloodpressure,beingoverweightorafamilyhistoryofCAD,youhaveanincreasedchanceofdevelopingblockageinyourcoronary arteries .Asyougetolder,youhaveagreaterchanceofdevelopingCAD .Inaddition,womenwhohavereachedmenopausehaveagreaterchanceofhavingCAD .

How do I know if I have Coronary Artery Disease?ThereareanumberofteststhatyourdoctorcanperformtohelpdetermineifyouhaveCAD .Atestthatmeasurestheelectricalactivityinyourheartiscalledanelectrocardiogram (ECG or EKG) .Astress testcanbedonetomeasuretheelectricalactivityinyourheartwhileyouareexercising .Thesetestsmayshowyourdoctorifpartofyourhearthasbeendamagedorisnotreceivingenoughblood .Todirectlydetermineifyourarteriesmaybeblockedornarrowing,yourdoctormayscheduleaprocedurewithacardiologist .Thisprocedureiscalledacoronary angiogramandisperformedinaCardiacCatheterizationLabbyinsertingadyeintoyourcoronary arteries .Bydoingthisprocedure,thecardiologistcanseeyourcoronary arteriesonanX-rayscreenandcanmakeadecisionofhowbesttotreatyou .

What is coronary artery disease

Right Coronary

Artery

Posterior Descending

Artery

Aorta Left Coronary

Artery

Circumflex Artery

Left Anterior

Descending Artery

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Therearemanydifferenttreatmentoptionsfortreatingcoronaryarterydisease .Theoptionsfocusonincreasingbloodflowtotheheart,alongwithchangestoyoureverydaylifestyle,includingdiet,physicalactivityandmedications .Thetypeoftreatmentyourdoctorrecommendsforyoudependsonyoursymptomsandhowmuchdamagehasbeendonetoyourheart .

TreatmentOptionsforCoronaryArteryDiseasemayinclude:

1 .Medications

2 .Balloon angioplasty

3 .Coronaryarterystenting

4 .Coronary artery bypass graft surgery (CABG)

1. Medications

Nitroglycerinmaybegiventorelievechestdiscomfortduetocoronaryblockages .Itdoesnottreattheblockageitself .Yourcardiologistmayprescribeanumberofmedications(aspirin,beta-blockers,cholesterolmedications,etc .)tothinyourbloodandtohelppreventblockageofthearteries .

Coronary artery disease treatment options

Coronary artery disease treatment options continued

2. Angioplasty

Aprocedureknownasangioplastycanalsotreatarterynarrowing .Athintubeknownasaguidecatheterisinsertedintothearteryatthegroinorwrist .Asmallballoonlocatedonthetopofasecondcatheterismovedthroughtheguidecathetertothesiteofthenarrowing .Theballoonistheninflatedtoreducetheblockage .Theballoonisdeflatedandremovedaftertheangioplastyisdone .Thepatientremainsawakewhilethecardiologistperformstheprocedure .Theproceduremayendhereoryoucouldhaveabare-metalordrug-elutingstentimplantedtohelpkeepthearteryopen .

3. Coronary artery stenting

Duringthisprocedureasmallmeshtubeisimplantedintothearterytowidenthearteryandrestoreadequatebloodflowtotheheart .Thismeshtubeiscalledastent .Oncethestentisplacedintothecoronaryartery,itisexpandedwiththeinflationofaballooncatheter .Thestentisleftinthearterytokeepitopenandhelppreventfurthernarrowingofthecoronaryartery .

4. Coronary artery bypass graft surgery (CABG)

Thissurgeryisalsocalledaheartbypassoropenheartsurgery .Yoursurgeonwillneedtotakeashortlengthofarteryfromyourinnerchestwalland/oraveinfromyourlegandsurgicallyattachitaboveandbelowtheblockedareaoftheheartartery .

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Plaque Before Treatment

Balloon Angioplasty Procedure

Result After Angioplasty

Plaque Before Treatment

Stent Procedure

Result After Stent Procedure

Side View of Coronary Artery

Coronaryarterystentsaresmallmeshtubesthatcanhelptoreduceblockageofacoronaryartery .Thestentisimplantedintoanarteryandexpandedtofitthesize,shapeandbendofthecoronaryartery .Thestentisproppedopentohelppreventanymoreblockages .Oncethestentisinplace,thestentwillremaininyourartery .Overtime,thearterywallwillhealaroundthestentasitcontinuestosupporttheartery .

Why are stents used?Manypatientswhoundergoballoon angioplastytreatmentwillexperienceare-narrowingoftheartery .Thisre-narrowingiscalledrestenosis .Thisre-narrowingofthecoronaryarterycanhappenmoreoftenfollowingaballoon angioplastyprocedurethanforpatientswhoreceiveastent .There-narrowingcanbecausedbyacombinationoffactorsincludingtheblockagereformingornewtissuegrowthwithinthetreatedarea .

Coronary artery with angioplasty

What are coronary artery stents

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What are coronary artery stents continued

Coronary artery with stenting

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What are the different types of coronary stents?

Therearetwokindsofstents,bare-metalanddrug-coated .Bare-metalstentsprovidesupporttohelpkeepthearteryopenafterangioplasty .Adrug-coatedstentisabare-metalstentwithaspecialdrugcoatingaddedtohelpreducethechanceofthearterybecomingblockedagain .Thedrugisreleasedfromthestentovertheperiodoftimeduringwhichre-blockageismostlikelytooccur .Thestentsweredesignedtobeveryflexible,allowingthemtofittheshapeofyourartery .

BostonScientificoffersbare-metalanddrug-elutingstents .Dependinguponyourspecificneeds,yourdoctormaychoosetoplaceabaremetal,drug-elutingorsomecombinationofthesestents .Therearedifferencesbetweenthetwostenttypes(suchastheneedforlonger-termdualantiplatelettherapywithdrug-elutingstents)thatyoushoulddiscusswithyourdoctor .PleasereferencetheIONPatientInformationGuideformoredetailsaboutthestent .

How does the drug coating and polymer work on a drug-eluting stent?

Polymer CoatingThestentiscoatedwithaproprietarypolymer,whichwasdevelopedspecificallyfordrug-elutingstents .Thepolymercarriesandprotectsthedrugbeforeandduringtheprocedure .Oncethestentisimplanted,ithelpscontroldrugreleaseintothecoronaryarterialwall .Thiscontributestoevenandconsistentdistributionofthedrugfromthestent .

Drug ReleaseThedrug-elutingstentiscoatedwithadrugandpolymerandhasbeendesignedtoallowforaconsistentandcontrolledreleaseofthedrugfromthestentsurfaceintothearterywalls .Boththeamountofdrugandreleaseratehavebeendeterminedsothathealingcanoccurwhileallowingtheprocessesleadingtorestenosistobeminimized,thusreducingtheneedforadditionaltreatmentinthestentedarea .

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Risks of treatment options

Youshouldnothaveadrugelutingstentplacedinyourcoronaryarteryifyouhaveanyofthefollowingconditions:

• Youareallergictothedrugorrelateddrugs

• Youareallergictothepolymer

• Youareallergictostainlesssteelorplatinumchromium

• Youareunabletotakemedicinesthatmakeyourbloodtakelongertoclot (alsocalledanticoagulants)

• Youareunabletotakemedicinesthatmakeyourbloodcellsslipperyandmakeit moredifficultforyourbloodtoclot(alsocalledantiplatelets)

• Youhaveablockagethatwillnotallowproperplacementofthestent

• Youareallergictothedyeusedduringtheprocedure(alsocalledcontrastagent)

• Yourdoctordecidesthatyouarenotabletohavetherequiredmedicationprior tostentplacement

Yourdoctorandthemedicalstaffwillmonitoryouduringandaftertheprocedureforcomplications .Ifacomplicationdoesoccur,yourdoctorwilldecidewhattypeoftreatmentyoumayneed .

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Theplacementofstentsinarteriesisdonetotreatblockagesandtotrytopreventre-narrowing .

As with any stent procedure, there is a chance that complications may occur, including, but not limited to, the following:• Airbubbles,tissueorclotswhichcanblock theartery(emboli)• Allergicreactiontothedrug• Allergicreactiontothepolymer• Allergicreactiontothemetalusedtomakethe stent(stainlesssteelorplatinumchromium)• Allergicreactiontothecontrastdye(which couldcausekidneyfailure)• Aneurysm• Bleeding(whichmayrequireablood transfusion)• Bruisingattheaccesssite• Bruisingwhichoccursonabloodvessel (pseudo-aneurysm)• Chestpainordiscomfort• Collectionofbloodintheliningoftheheart• Coronaryspasm• Death• Emergencybypasssurgery• Heartattack• Highorlowbloodpressure• Inadequatesupplyofbloodtotheheart• Infectionand/orpainattheaccesssite• Injuryortearingofartery• Irregularheartbeat(arrhythmia)• Movementofthestenttoanunintended location• Pluggingofthestentwithbloodclots

• Re-narrowingofthetreatedartery(restenosis)• Shock/pulmonaryedema• Sideeffectsduetocontrastdye,heparinor othermedications• Strokeorotherneurologicalproblems• Totalblockage(occlusion)oftheartery• Unnaturalconnectionbetweenveinandartery (asterio-venousfistula)• Arterialtraumarequiringsurgicalrepairor reintervention• Worseningofheartandlungfunction

There is a chance that complications may occur relating to the drug (based on studies of patients who used the drug for a prolonged period of time) or the polymer which include:• Abnormallivertestlevels• Allergicorimmunologicreactiontothedrug• Allergicreactiontothepolymerorpolymers withsimilarchemicalstructures• Anemia• Bloodtransfusion• Changesinbloodprofile(decreaseinthenumber ofwhiteandredbloodcellsandplatelets)• Changesofthetissueinthearterialwallincluding inflammation,cellinjuryandcelldeath• Disturbancesofthegastrointestinal(GI)tract andstomach• Lossofhair• Musclepain/jointpain• Nervediseaseinarmsandlegs

Theremaybeotherpotentialadverseeventsthatareunforeseenatthistime .

Risks of treatment options continued

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Before your coronary artery stenting procedure:

• Tellyourdoctoraboutanymedicationsyouaretaking .

• Letyourdoctorknowaboutanyallergiesyouhave .Itisimportantheor sheknowsaboutallergiestocontrastdye,iodine,cobalt,chromium, nickel,titanium,stainlesssteel,platinumorplastics .

• Tellyourdoctorifyoucannottakeaspirinorbloodthinningmedicines . Thesemedicationsareusuallyprescribedbeforeandafteryour procedure .

• Makesureyouunderstandthepossiblerisksandbenefitsofyour coronarystentprocedure .

Below is a typical checklist. Your doctor may ask you to go through this before your procedure:

• Donoteatordrinkanythingaftermidnightonthenightbefore yourprocedure .

• Followtheinstructionsyoureceivefromyourdoctorandnurses .

• Takeallyourmedicationswithyou .

• Youmaybegivenasedativetorelaxyoubeforestartingyourstent procedure .Thesedativecanmakeyousleepy .

Before your coronary artery stenting procedure

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During a typical coronary artery stenting procedure

1 .YouwillbetakentoanareaofthehospitalcalledtheCardiacCatheterizationLaboratory .Whileinthecathlab,youmaybegivenasedativethatwillmakeyoufeelsleepyduringtheprocedure .

2 . Asmallpunctureismadeinyourarmorgroin .Aneedleisusedtogainaccesstoyourarteryandaguidecatheterandguidewirearefedthroughthearteryandmovedupintothecoronaryartery .AllofthisisdoneusingX-raysforaguide .

3 . Thediseasedarteryfirstneedstobeenlargedtomakeroomforthestent .Todothis,thedoctorplacesasmall,deflatedballoonovertheguidewireandthroughthecathetertotheblockedareaofthecoronaryartery .Whentheballoonisinthecorrectposition,itisinflated .Thispushestheplaquebuildupasideandreopensthearterytorestorebloodflow .

4 . Theballoonisdeflatedandremoved,andasmallmetalmeshtubecalledastentisadvancedintothesameblockedareaofthearteryandexpandedagainstthearterywalltofittheshapeofyourartery .Yourdoctormaychoosetoexpandthestentbyusinganotherballoon .Thisistomakesurethestentisinbettercontactwiththeartery .

5 . Ifyourdoctorplacesadrug-elutingstentintoyourartery,adrugwillbereleasedfromthestentoveraslowperiodoftime .

6 . Afterthestentisimplanted,thecatheterandwireareremovedandthepuncturesiteisclosed .Thestentremainsinplacepermanentlyandisdesignedtohelpkeepthearteryopenandpreventfuturenarrowingofthecoronaryartery .

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After a typical coronary artery stenting procedure

• Youmayfeelsleepyfromthesedativegiventoyou .Thiswillwearoff overthenextfewhours .

• Youwillbetakentoaunitwherenursesanddoctorscanmonitoryou .

• Youwillbeaskedtostayinbedforseveralhours .Youwillbeaskedto keepyourarmorlegstraightsotheentrysitecanheal .

• Youmayneedtostayinthehospitalbeforeyoucangohome .

• Youshouldfollowyourdoctor’srecommendationsandletthemknow ifyouareexperiencinganyofthefollowing:

– Chestpain

– Shortnessofbreath

– Suddenweaknessorparalysisoftheface,armorleg

– Pain,bleedingorinfectionattheentrysiteinyourarmorleg

– Anyotherunexplainedsymptoms

• Youcanreturntonormalactivitiesgradually .Checkwithyourdoctor aboutphysicalactivities .

• Youshouldnotstoptakingyourmedicationsunlessyouareaskedto stopbythedoctorwhoimplantedyourstent .

• Youshouldkeepallofyourfollow-upappointments,including bloodtesting .

• YoushouldcarryyourStentImplantCard .

• YoushouldalwaysshowyourdentistormedicaldoctoryourStent ImplantCard .

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Yourcardiologistmayprescribeanumberofmedicationstothinthebloodandpreventbloodclotsfromformingandadheringtothesurfaceofthestent .ThesemedicationswillincludeaspirinandbloodthinningdrugssuchasPlavix®,Ticlid®orEffient®(Prasugrel) .Itisextremelyimportantthatyoufollowyourdoctor’sinstructionsonwhatmedicationstotake .If you stop taking these medications before being instructed to do so by your cardiologist, the chances of blood clot formation on the stent, subsequent heart attack or even death are increased.

Ifyouplantohaveanytypeofsurgeryordentalworkwhichmayrequireyoutostoptakingthesemedicationsprematurely,youandyourcardiologistshoulddiscusswhetherornotplacementofastentistherighttreatmentforyou .

Ifsurgeryordentalworkisrecommendedwhichwouldrequireyoutostoptakingthesemedicationsprematurelyafteryou’vereceivedthestent,youandyourdoctorshouldcarefullyconsidertherisksandbenefitsofthisadditionalsurgeryordentalworkversusthepossiblerisksfromearlydiscontinuationofthesemedications .

Ifyoudorequireprematurediscontinuationofthesemedicationsbecauseofsignificantbleeding,thenyourcardiologistwillbecarefullymonitoringyouforpossiblecomplications .Onceyourconditionhasstabilized,yourcardiologistwillprobablyputyoubackonthesemedications .

Follow-Up Examinations

Youwillneedtoseethecardiologistwhoimplantedyourstentforroutinefollow-upexaminations .Duringthesevisits,yourdoctorwillmonitoryourprogressandevaluateyourmedications,theclinicalstatusofyourcoronaryarterydisease,andhowthestentisworkingforyou .

Medications

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Frequently Asked Questions

Can the stent move or rust? Oncepositionedbyyourdoctor,thestentdoesnotmoveonitsown .Itismanufacturedsothatitwillnotrust .

Can I walk through metal detectors with a stent? Yes,withoutanyfearofsettingthemoff .

How soon can I go back to work? Themajorityofpeoplereturntoworkwithinafewdaysfollowingtheprocedure .

What if I still have pain? Ifyouexperiencepain,immediatelyinformyourcardiologistorthecenterwheretheprocedurewasperformed .

Can I undergo MRI or scanner testing with a stent? MRIsafetytestinghasshownthatthecoronarystentisMRConditionalandthatapatientwithacoronarystentmaysafelyundergoanMRIscanundercertainconditionslistedontheStentImplantCard .PriortoundergoinganMRIscan,informyourdoctororMRtechnologistthatyouhaveacoronarystentandshowthemyourStentImplantCard .

Can I play sports? Yourdoctorwilltellyouwhatsportsyoucanplayandwhenyoucanstartthem .

What should I change in my diet? Yourdoctormayprescribealow-fat,low-cholesteroldiettohelpreducethelevelsoffatinyourbloodandreduceyourrisk .

Angina PectorisSymptomsexperiencedwhentheheartmuscleisnotreceivingadequateoxygen(mayincludechest,arm,jaworbackpain,shortnessofbreath,nausea,vomiting) .

AngioplastyAminimallyinvasivetreatmenttoopenblockedcoronary arteries .Alsoknownaspercutaneous transluminal coronary angioplasty (PTCA) .

AtherosclerosisAdiseaseinwhichtheflowofbloodtotheheartisrestrictedwithplaquedepositsand,therefore,lessoxygenandothernutrientsreachtheheartmuscle .Thismayleadtochestpain(angina pectoris)ortoaheartattack(myocardial infarction) .

Balloon AngioplastyOpeningtheblockedarterybyusingaballooncatheterthatisinflatedinsidetheartery .

CatheterAsmall,thinplastictubeusedtoprovideaccesstopartsofthebody,suchasthecoronary arteries .

Coronary AngiogramAtestinwhichcontrastdyeisinjectedintothecoronary arteriesallowingthedoctortoseethearteriesonanX-raymachine .

Coronary ArteriesThearteriesthatsurroundtheheartandsupplybloodcontainingoxygenandnutrientstotheheartmuscle .

Coronary Artery Bypass Graft Surgery (CABG)Openheartorbypasssurgery .Asectionofanarteryorveinfromyourchestorlegisharvestedandsurgicallyattachedtoacoronaryarterybelowtheblockedareaoftheheart .

Coronary Artery Disease (CAD)Diseaseaffectingthecoronary arteriesthatsurroundtheheartandsupplybloodtotheheartmuscle .

Electrocardiogram (ECG/EKG)Atestthatrecordschangesintheelectricalactivityoftheheart .Mayshowwhethersectionsoftheheartmusclehavebeendamagedduetoinsufficientbloodoroxygenflowtotheheart .

Glossary

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Glossary continued

In-Stent RestenosisRecurrentblockageornarrowingofapreviouslystentedareainanartery .

LumenTheinnerchannelofanartery .

Magnetic Resonance Imaging (MRI) Anon-invasivewaytotakepicturesofthebody .MRIusespowerfulmagnetsandradiowaves,unlikex-raysandcomputedtomographic(CT)scanswhichuseradiation .

Myocardial InfarctionPermanentdamagetothehearttissueandmuscleduetotheinterruptionofthebloodsupplytothearea .Commonlyreferredtoasaheartattack .

Percutaneous Transluminal Coronary Angioplasty (PTCA)SeeAngioplasty .

PlaqueAccumulationorbuildupofcholesterol,fattydeposits,calciumandcollageninacoronaryvesselthatleadstoblockagesinthecoronary arteries .

RestenosisRecurrentblockageorre-narrowingofapreviouslytreatedartery .

StentAnexpandablemetaltubularstructure(lattice)thatsupportsthevesselwallandmaintainsbloodflowthroughtheopenedartery .

Stress TestAtestthatrecordstheheart’selectricalactivitywhilethepatientexercises .Mayshowwhetherpartsoftheheartmusclehavebeendamagedandifthereisinsufficientbloodoroxygenflowtotheheart .

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