Amanda Wilde (Host): Welcome to DocTalk, presented by Montefiore Saint Luke's Cornwall. I'm Amanda Wilde. I'm joined by Dr. Ahmad A. Hadid, Medical Director of the Kaplan Family Center for Cardiovascular Medicine and interventional Radiology at Montefiore St. Luke's Cornwall. We're talking about angioplasty, what it is, when it's needed, and what patients can expect before, during, and after the procedure. Welcome, Dr. Hadid. Glad to have you back.

Ahmad A. Hadid, MD: Thank you. Thank you.

Host: Let's talk about the definition of angioplasty. What exactly is it, and how is it different from bypass surgery for treating blocked heart arteries?

Ahmad A. Hadid, MD: So angioplasty, what it means, the term angio is a blood vessel, plasty is like fixing. And we knew for a while that a heart attack is caused by blockages in the coronary artery and the blockage—we call it fissure or rupture—and cause a clot and prevent totally or subtotally the blood flow to the heart muscle. And that process, that disease, obviously, it progressed through many stages. First, obviously, to take a picture of the artery and define the blockages, what can be done for those.

First, actually, angioplasty was done in the peripheral artery, it was done by Dr. Dotter, that even he discovered that by chance, where he put a catheter or a plastic tube. He was doing an angiogram or a picture of the artery. And, obviously, the artery has narrowing, and he was doing a test angiogram, taking pictures of the artery to see the blockage. And in the process, he pushed a catheter through a narrowed artery. And through that, mechanically, it did open up the blockage.

And when he saw a patient later on, like a week or two in the follow-up, the patient told the doctor, "You know, I feel better. You know, I can walk better." So right away, the light went on in his head that the catheter went through the blockage and it did open it up and gave more blood flow, and that's how the patient felt better. That was done in the peripheral artery. And then, Dr. Gruentzig, one of the first doctors to perform angioplasty, he tried to apply that to the coronary artery. And he worked obviously with the industry and made the first balloon and he did do first coronary angioplasty in the '70s, actually in 1977. And that was the first case, and it worked good.

In the beginning, it was a riskier procedure. It's documented that he had two open heart surgery rooms ready just in case something goes wrong for the first few cases. Because in the beginning, the balloon angioplasty, what it does is you put the balloon in the blockage, you inflate the balloon, to open up the blockage, and you take the balloon out.

And up to one in seven cases, the artery itself, we call it rupture or call—not rupture, but like dissect. And instead of the blockage getting better or the flow getting better, it can get worse. But that's, you know, a minor incidence. That's in the history of that.

And then, the stent was invented. And the stent is a scaffold to keep the artery open. You put the stent, you put the balloon, inflate the artery. And when you take the balloon, you keep the stent, which is a scaffold. It is like a spring to keep the artery open. That was a major advance in the late '80s, early '90s in fixing the coronary artery disease.

And, after the stent, obviously, because the stent itself is a foreign body, it results in in-stent restenosis, where the blockage comes back, then the scientists really developed a drug-coated stent we call it. And first initiated in 2003 or first approved actually in 2003 with the Cypher stent where they put a medicine on the stent to prevent the scarring and the narrowing. And that kept the artery open more and decreased the narrowing back. And that's one of the obviously major advances in interventional cardiology.

Right away, it became the standard, as I said 2003. We're lucky to have it, and it helps. And obviously, even the stent itself improved with time, that thinner stent, you know, we call it polymer, where it's a substance to keep the drug that prevent restenosis on the stent for a longer time.

So, these are technical forms of the stent. I'm sorry if I went too long about that. But that's kind of important for interventional cardiology here in St. Luke's Hospital.

Host: Yeah. There definitely is a distinction here. Is angioplasty with stent placement more often chosen by a cardiologist than balloon angioplasty alone?

Ahmad A. Hadid, MD: Angioplasty came first. Obviously, balloon started first. And balloon, you inflate the balloon, and you open the blockage, and you take the balloon out. And the artery itself is like a rubber band, more or less. And, first of all, after they take the balloon, there is something called a recoil. It's like a rubber band when you stretch it open and you take the pressure, and it goes back to its own thing. That's number one.

And two, there's a phenomenon called dissection, which actually the balloon, this is how it works. Dissection is a little tear in the artery. And when you take the balloon, sometimes, most of the time, it heals. But sometimes it doesn't heal. And that's where they put the stent on the balloon, and they inflate the stent, and they leave the stent in place. It's like an implant to keep the artery open. It's like a scaffolding. And that was a major, major advance.

The first stent really was approved in the United States as we call it bailout. It was approved for, like, if the artery closed and called acute closure, you employ or you deploy the stent to keep it open. That's how it started. So, the stent, it made the angioplasty a safer procedure and more predictable.

Host: That's just what I was going to ask, is how safe is angioplasty today, and what are the most common short-term or long-term risks that patients and families should know about?

Ahmad A. Hadid, MD: Yes. It's fairly safe. Obviously, if it is done by a skilled operator and skilled team, and it's done with the appropriate selection. one important point, that here in St. Luke's Hospital, we do angioplasty and stenting, and we do select the patient that's appropriate for that.

Most of the patients being done ain are low to moderate risk. Anybody with high risk, we refer them to a tertiary care cente. And this has been always the Case. Anybody who had disease that should not be done here, obviously, the sicker the patient, the more complicated. These are the factors that affect the outcome.

Angioplasty in general, really the risk of angioplasty, the serious risk is less than 1% or so. There's always risk of bleeding. There is risk of artery damage, et cetera, risk of stroke, risk of heart attack. And death, obviously, it can happen. But all those risks are very, very low considering. It's really, as I said, like 1% or less. And it's really done to help patients, done to prevent heart attack, done to save a life. You know, especially the emergency one, you know, when the patient is having a heart attack, it makes all the difference.

And we have a very good team here in St. Luke's. And our data, it's been good. We have a good review system. We have a director who goes over all the cases. We discuss all the cases, all the complication, all the data we have to make sure that we keep up the good standard and obviously to help patients more.

And also, New York State requires of us to report all those cases. So, there is a very good system and we've been very successful with that. And it's a really good thing that works both ways, the volume. Even for acute myocardial infarction, when we start the program, like the state require, let's say about 40 heart angioplasty, primary angioplasty for heart attack patient. We had that. We had the need for that. And we've been doing that, and actually even have grown to about like 50 cases per year. And also, the community need, the average travel time to the patient, and transfer in an emergency to cardiac surgery.

That was one on our application that we can fly the patient to Westchester, Medical Center for emergency. You know, sometimes, in a complication, it's unlikely, but it can happen. And as I said, always, always, we have a good selection for no high-risk procedure done here. Obviously, if the patient comes with heart attack and, God forbid, like, dying, you have to do the best you can. And we have saved multiple patients over the years.

Host: And what you've just described is how you assure that all expertise and technology available is applied to each patient, no matter what their situation. What does recovery and follow-up after the procedure look like?

Ahmad A. Hadid, MD: Yes. Yes. So, this is another advance. By the way, I just want to mention angioplasty in the beginning, it was that to try to fix the blockage on awake and alert patients. You know, we do give them some sedation. Some patients get nervous, we give them some anxiolytic or medications to decrease anxiety. But the patient is usually awake, alert, responsive. We ask them how they're feeling, and we always have a feedback. When we started doing this, even with the cardiac catheterization through the years, I remember like 30 years ago or so, even patients with general cardiac catheterization, we used to keep them overnight.

And then, the diagnostic coronary angiogram is done as an outpatient patient, comes in, have the procedure, go. And for about like 10 years or so, even patients who had angioplasty, they come same day, have the procedure, have angioplasty, have a stent. Most of the time, they go home. Most of the patients, they do. Of course, if there's any complication, if there's any need, we keep them overnight. And we've been very, very successful with that. And the outcome is great. The outcome is great. And patients appreciate that. Doing the procedure here in the community, for their family to see them, to visit them, to bring them and take them, it's a major, major advantage.

I do remember 30 years ago when most of the patients, they used to go out of town to like New York City and other centers. And nowadays, it's more convenient and it's better, especially for the older patients to have their family around. It's a major, major plus.

Host: Definitely a source of comfort and the advancements you've seen in this field over your 30 years are also a source of encouragement. Dr. Hadid, thank you so much for providing clarity on the angioplasty procedure.

Ahmad A. Hadid, MD: Thank you. Thank you very much. Thank you for allowing me to participate in this event

Host: That was Dr. Ahmad A. Hadid, Medical Director of the Kaplan Family Center for Cardiovascular Medicine and Radiology at Montefiore St. Luke's Cornwall. To learn more about cardiac services, visit montefioreslc.org. Please remember to subscribe, rate, and review this podcast and all other Montefiore St. Luke's Cornwall podcasts. Thanks for listening to DocTalk, presented by Montefiore St. Luke's Cornwall.