Percutaneous Transluminal Coronary Angioplasty (PTCA): What is it?

By Cristiano Antonino On Nov 27, 2022

Percutaneous Transluminal Coronary Angioplasty (PTCA) is an interventional cardiology technique first performed in 1977 by a German physician, Dr Andreas Gruentzing

It is estimated that between 500,000 and 600,000 angioplasties are currently performed worldwide each year and that in the United States, with 300,000 procedures per year since 1990, angioplasty has surpassed bypass surgery.

In Italy, the method’s expansion has seen slower growth due to organisational reasons: in order to cope with possible acute complications linked to the procedure, angioplasty must necessarily be performed in the presence of a cardiac surgery standby, with a cardiac surgery operating theatre ready when needed for the immediate performance of an emergency restorative operation; obviously, this limits the operational possibilities of the various centres.

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What percutaneous transluminal coronary angioplasty consists of

The first step in performing percutaneous transluminal coronary angioplasty is the visualisation of the coronary arteries by means of coronarography.

Once the stenotic section of the coronary vessel is highlighted, a catheter equipped at its end with a small inflatable balloon is advanced to that point.

Inflating the balloon at a pressure of several atmospheres induces a barotrauma, which crushes the atherosclerotic plaque obstructing its lumen along the vessel walls, thus eliminating the stenosis of the vessel and restoring good flow downstream.

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This is a very elegant and sophisticated technique that requires great skill on the part of the operators and is the result of a very high level of bioengineering technology in the design and construction of the catheters, which are high-precision, highly sophisticated and very expensive instruments.

Initially, angioplasty was performed in selected cases that gave the greatest guarantee of success: on a single vessel, when this was easily reached by the catheter, and in the presence of stenosis that was not long and not tight.

Later, as the technique was perfected and the materials improved, the method was also increasingly used in complex situations, e.g. on several vessels at the same time.

Whenever possible, angioplasty is also usefully employed in the treatment of venous bypass occlusion.

How to prepare for percutaneous transluminal coronary angioplasty

The procedure is performed in the haemodynamic room, does not require narcosis, and involves a hospital stay of only 24-48 hours.

In general, immediate dilatation success rates are very high, with more than 90% of cases treated overall; however, angioplasty presents a major problem, which is still unresolved: in between 30% and 40% of cases, the result obtained initially disappears over time, so that the dilatation obtained is cancelled and the stenosis reappears.

The highest incidence of restenosis generally occurs quite early, within the first six months after dilatation.

In addition to pharmacological treatments, which have on the whole proved to be poorly effective, other interventional avenues have been attempted to avoid or limit the incidence of restenosis.

The best results, in this respect, have been obtained with the use of prosthetic implants such as stents, which are small cages or very elastic, metal fenestrated tubes that, again guided by the catheter, are introduced into the vessel until they reach the stenosis and positioned, dilated and left in place.

The use of stents has led to a reduction in the incidence of restenosis at a rate of less than 20%; moreover, stents have proved very effective both in obtaining more satisfactory and stable results after balloon dilatation and, above all, in obviating acute occlusion of the vessel immediately after angioplasty, a very risky and dreaded complication.

Irrespective of the possible use of stents, in the event of restenosis it is generally also possible to repeat the dilation procedure

The risks in the case of percutaneous transluminal coronary angioplasty are, on the whole, quite low and acceptable: the risk of procedure-related death is recently estimated to be around 0.3%, the risk of infarction around 0.9%, and the risk of having to resort to emergency bypass surgery around 1.8%.

The choice, in the individual patient, must be made on the basis of an exact prediction of the best results and expected benefits with each of the treatment options.

On the other side of the scales are the difficulties and risks specific to each of the therapeutic choices, such as: ineffectiveness of medical therapy or impossibility of performing it because of serious intolerance; prohibitive conditions for bypass due to very old age or serious concomitant pathologies; high risk associated with angioplasty or foreseeable serious difficulties in its performance.

Nowadays, economic evaluations cannot be disregarded either: bypass is certainly more expensive than angioplasty, however, the possible need to repeat the dilation procedure or the use of stents can lead to costs that are very close to being equal.

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