The term balloon angioplasty is commonly used to describe the inflation of a balloon within the<unk>  artery to crush the plaque into the walls of the artery. While balloon angioplasty is still done as a part of nearly all<unk> s, it is rarely the only procedure performed. Other procedures done during a<unk>  include: * Implantation of stents * Debulking strategies * Rotational atherectomy * Orbital atherectomy * Laser atherectomy * Brachytherapy (use of radioactive source to inhibit restenosis) *<unk>  intravascular lithotripsy (IVL) The angioplasty procedure usually consists of most of the following steps and is performed by a team made up of physicians, physician assistants, nurse practitioners, nurses, radiographers, and endovascular specialists; all of whom have extensive and specialized training in these types of procedures. # The femoral artery in the leg or the radial artery in the arm is punctured with a needle and a small wire is passed into the artery. This procedure is often termed<unk>  access. # Once access into the artery is gained, a "sheath introducer" is placed over the wire into the artery to allow catheters to be advanced into the artery and to control bleeding. # Through this sheath, a long, flexible, soft plastic tube called a "guiding catheter" is pushed. The tip of the guiding catheter is placed at the mouth of the<unk>  artery. The guiding catheter allows for radio-opaque dyes (usually iodine-based) to be injected into the<unk>  artery, so that the disease state and location can be readily assessed using real time X-ray visualization. # During the X-ray visualization, the cardiologist estimates the size of the<unk>  artery and selects the type of balloon catheter and<unk>  guidewire that will be used during the case. Heparin (a "blood thinner" or medicine used to prevent the formation of clots) is given to maintain blood flow. Bivalirudin when used instead of heparin has a higher rate of myocardial infarction but lower rates of bleeding. # The<unk>  guidewire, which is an extremely thin wire with a radio-opaque flexible tip, is inserted through the guiding catheter and into the<unk>  artery. While visualizing again by real-time X-ray imaging, the cardiologist guides the wire through the<unk>  artery to the site of the stenosis or blockage. The tip of the wire is then passed across the blockage. The cardiologist controls the movement and direction of the guidewire by gently manipulating the end that sits outside the patient through twisting of the guidewire. # While the guidewire is in place, it now acts as the pathway to the stenosis. The tip of the angioplasty or balloon catheter is hollow and is then inserted at the back of the guidewire—thus the guidewire is now inside of the angioplasty catheter. The angioplasty catheter is gently pushed forward, until the deflated balloon is inside of the blockage. # The balloon is then inflated, and it compresses the atheromatous plaque and stretches the artery wall to expand. # If a stent was on the balloon, then it will be implanted (left behind) to support the new stretched open position of the artery from the inside. Types of stent A<unk>  stent placed by<unk> . Traditional bare-metal stents (BMS) provide a mechanical framework that holds the artery wall open, preventing stenosis, or narrowing, of<unk>  arteries. Newer drug-eluting stents (DES) are traditional stents with a polymer coating containing drugs that prevent cell proliferation. The antiproliferative drugs are released slowly over time to help prevent tissue growth — which may come in response to the stent — that can block the artery. These types of stents have been shown to help prevent restenosis of the artery through physiological mechanisms that rely upon the suppression of tissue growth at the stent site and local modulation of the body's inflammatory and immune responses. The first two drug-eluting stents to be utilized were the paclitaxel-eluting stent and the sirolimus-eluting stent, both of which have received approval from the U.S. Food and Drug Administration. Most current FDA-approved drug-eluting stents use sirolimus (also known as rapamycin), everolimus and zotarolimus. Biolimus A9-eluting stents, which utilize biodegradable polymers, are approved outside the U.S. However, in 2006, clinical trials showed a possible connection between drug-eluting stents and an event known as “late stent thrombosis” where the blood clotting inside the stent can occur one or more years after stent implantation. Late stent thrombosis occurs in 0.9% of patients and is fatal in about one-third of cases when the thrombosis occurs. Increased attention to antiplatelet medication duration and new generation stents (such as everolimus-eluting stents) have dramatically reduced concerns about late stent thrombosis. Newer-generation<unk>  technologies aim to reduce the risk of late stent thrombosis or other long-term adverse events. Some DES products market a biodegradable polymer coating with the belief that the permanent polymer coatings of DES contribute to long-term inflammation. Other strategies: A more recent study proposes that in the case of population with diabetes mellitus—a population particularly at risk—a treatment with paclitaxel-eluting balloon followed by BMS may reduce the incidence of<unk>  restenosis or myocardial infarction compared with BMS administered alone. After placement of a stent or scaffold, the patient needs to take two antiplatelet medications (aspirin and one of a few other options) for several months to help prevent blood clots. The length of time a patient needs to be on dual antiplatelet therapy is individualized based risks of ischemic events and bleeding risk. Thrombus aspiration In primary<unk> , angiography may demonstrate thrombus (blood clots) inside the<unk>  arteries. Various studies have been performed to determine whether aspirating these clots (thrombus aspiration or manual thrombectomy) is beneficial. At the moment there is no evidence that routine clot aspiration improves outcomes. Complex lesions Lesions with a high degree of calcium deposition within the vessel wall, especially if the calcium is circumferential, are considered to be hard to dilate in regards to balloon angioplasty. Complex lesions are one of the key predictors of poor outcome in<unk>  <unk> , hence calcium lesion modification is needed before implantations of stents. The aim is to create cracks in the calcium within the vessel wall in order to increase the likelihood of successful expansion of the stenosis and delivery of the final stent. This is traditionally achieved by balloon angioplasty or debulking strategies including rotational, orbital and laser atherectomy. However,<unk>  intravascular lithotripsy using acoustic shockwaves is a novel approach for treating superficial and deep calcium in the vessel wall.
Percutaneous coronary intervention
Transmyocardial revascularization
Coronary stent
Cardiomyoplasty
Valvulotomy
Totally endoscopic coronary artery bypass surgery
Hybrid coronary revascularization
Coronary artery bypass surgery