Trusting In Angioplasty The Procedure Is Common - Even More Than Bypass Surgery - Though Not Minor. As Feared, However, Complications Arose.

Posted: November 18, 1999

Lying on the narrow, hard table in the catheterization room, I stared up at the mountain of X-ray equipment hanging over me. I was waiting for the doctors to push a wire up a blood vessel in my leg and into one of the arteries of my heart.

Partially covered with only a green paper bathrobe and sheet, I felt utterly vulnerable as the nurses bustled efficiently, preparing me for angioplasty. The equipment blocked my view. I could not see the doctor at the other end of the table, but I could feel his fingers looking for the femoral artery in my leg, through which doctors would introduce the tubelike catheter and guide wires.

The plan was to push a catheter tipped with a balloon into my coronary arteries until it lay over the plaque that clogged them. Then, the balloon would be inflated, pressing the plaque against the arterial walls and opening the vessels.

I thought about the three surgeons who had urged me to have a coronary-bypass operation instead.

Although less radical than surgery, angioplasty is not a minor procedure, they told me. Things can go wrong. The catheters can rip the vessel or temporarily block blood flow and cause a heart attack. With several blocked arteries, they had said, I could suffer a fatal heart attack. Why risk it with a procedure that was not going to produce as good results?

Despite the disconcerting warnings, the odds were only four in a thousand that the doctors in this room were about to kill me. That was 5 to 10 times better than the surgeons' statistics.

"A little pinch," said a disembodied voice at the other end of the table. It was Bruce Klugherz, the doctor assisting John W. Hirshfeld Jr.

I felt a slight prick near my groin as Klugherz injected the drug to numb the area that would be sliced open to reach my femoral artery.

I remembered the first time I saw angioplasty - as a medical writer, 25 years before. It was a medical breakthrough. Doctors reamed out a blocked artery in the leg of a man who could hardly walk because the pain was so bad.

The next day, he was up and about. I said to the doctor that this would be a great way to treat heart disease. I remember how he shook his head and said it was far too dangerous to do angioplasty on the arteries lying on top of the heart, the ones that nourished it with blood.

Last year, angioplasty was used to ream out the coronary arteries of more than half a million Americans. It was done on more patients than even bypass surgery, one of the most frequently performed operations in the country.

"All right, we are about ready to begin," said another voice. Hirshfeld, director of the cath lab at the Hospital of the University of Pennsylvania, had just entered the room and suddenly appeared on my right side.

He looked down and smiled, as though to say: "Forget what those other doctors said. I know what I'm doing, and everything is going to be just fine."

A soft-spoken, understated man, he never would have said something so cocky, but that was how I chose to interpret the smile, which at that moment was far more reassuring than all the survival statistics.

Wearing a bright red lead tunic for protection against the X-rays he would use to visualize my arteries, Hirshfeld disappeared to join his colleague at the other end of my body.

My right coronary artery was totally blocked. It probably had been that way since my 1980 heart attack and was beyond the reach of angioplasty. Two major branches of the artery running down the left side of my heart were partially blocked and the cause of increasingly frequent pain. My heart was getting only half of the blood that a healthy coronary-artery system delivers.

The plan was to dilate the LAD (left anterior descending) branch, which feeds the front half of the heart. If that was successfully opened, the doctors would go after the blockage in the "obtuse marginal segment of the circumflex branch," which feeds the back of the heart.

The surgeons had questioned whether the cardiologists could safely reach either blockage. The top part of my LAD had twists and turns that might be difficult to navigate with a catheter. The segment of the circumflex was probably too small for the catheters, the surgeons had said.

According to Hirshfeld, this might have been true a year or two ago, but the new devices are so small and flexible that they can reach once-inaccessible areas.

Hirshfeld conceded that mine was not an easy case, but he thought he could dilate the LAD and was "reasonably confident" that he could do the circumflex.

If successful, he thought, he could boost the amount of blood nourishing my heart by more than 50 percent - to about 80 percent of normal. This would make it possible for me to lead a fairly active, pain-free life, but I still would have to take heart drugs and probably would get chest pain with a lot exertion, especially after eating. On the other hand, coronary-bypass surgery probably would restore blood flow to normal and eliminate most, if not all, symptoms of heart disease.

"You're going to feel a little pressure, Don," Hirshfeld said.

There was no pain, but I could feel him pushing near my groin as he put a sheath into my artery to make it easier to introduce the catheters and guide wire. Because arteries have no pain-sensing nerve endings, I couldn't feel anything as they pushed the catheter up the femoral artery to my heart.

I heard a whirring and grinding. Hirshfeld had activated the contraption over my chest, and a movie camera started taking X-ray pictures of my heart and arteries, which were displayed on a television screen above the cath table.

Hirshfeld chatted as the procedure began, but suddenly became quiet. I asked him some questions, but, uncharacteristically, he did not reply.

Occasionally, I could hear hushed words between him and Klugherz. I sensed something was wrong.

They had successfully pushed three feet of guide wire up through the artery in my leg, high into my chest, and then down toward the coronary arteries. But, as I later would learn, they were having trouble navigating the balloon-tipped catheter through the turns above the LAD blockage, just as one of the surgeons had predicted.

"Have you gotten through the LAD?" I called out, hoping that the catheter's circuitous journey was uneventful.

"We're doing fine," Hirshfeld said. The way he said it didn't sound as if they were doing fine.

There was some more pushing and tugging near my groin. The device on top of me came alive again with a clatter.

I felt a slight tightness in my chest, vaguely similar to the angina that happened when I overworked my compromised heart.

Hirshfeld had just inflated the balloon, temporarily blocking all blood through that artery.

"Are you through with the LAD yet?" I called out again.

"Nope, not yet."

I looked at a clock on the wall. It was 11 a.m. After a torturous trip through the curves of my artery, Hirshfeld had finally reached the plaque and inserted a metal stent.

About a half-inch long, stents are sausage-shaped tubes of scaffolding that the inflated balloon expands and presses into the plaque. The stents work the way lath does in holding up plaster.

Hirshfeld said something to Klugherz, too hushed for me to understand. Later, I would learn that he was not happy with the way the stent looked on the video screen. At its edge was rough tissue. The angioplasty had torn the lining of the arterial wall, which could prompt a clot to form and cause a heart attack.

This type of complication used to send patients as emergencies to the operating room. Again, I felt movement near my groin area, followed by the clatter of the movie camera. Instead of rushing me off to a surgeon, Hirshfeld put a second stent through the first one, closing up the tear as though the stent were a metallic Band-Aid.

But the tissue tore around the end of the second stent, forcing Hirshfeld to put a third one through the first two, like extensions of a collapsible telescope - at a cost of $1,500 per stent. The third one worked, and Hirshfeld moved on to the next artery.

"Are you still fooling around with the LAD?" I asked, having no idea of the construction job that had just taken place inside my body.

"All done," Hirshfeld said. "We're doing the circ now."

I looked at the clock. It was 11:25 a.m. All told, it had taken about 25 minutes to dilate and stent the LAD, a job that normally took Hirshfeld 10 minutes.

A few minutes later, I heard the wonderful words:

"OK, we're finished."

Though I'd been counting the minutes, the announcement, so abrupt, seemed anticlimactic. That's it? It's all over?

As they wheeled me to the intermediate coronary-care unit for my overnight stay, I felt as though a weight had been taken from my shoulders.

For the first time in three months, I was free to think again about all the wonderful things in my life, free from the obsession with the angina and the worries about what I should do about it.

Epilogue

I returned to work two days after the procedure and resumed my usual activities, without angina.

I am still taking drugs to ease the workload on my heart, and occasionally - maybe once or twice a month - I have to take a nitroglycerin pill, usually only when I exert myself after eating. My cardiologist thinks adjustments in my medicines may eliminate even that.

The drugs have helped bring my very high total cholesterol level - 305 - to below the U.S. average. I am hoping that the drugs will slow, if not stop, the progression of my disease.

I realize that this may be overly optimistic - thinking that drugs will stop atherosclerosis - and I could be facing a crisis again in a few years. But by then, some of the uncertainty and problems that now trouble this fast-moving field may well be resolved.

And who knows? Maybe the gene-therapy people will have found a way to ease angina with a pill that grows blood vessels around clogged arteries. They have started human trials with such a drug, and it looks encouraging.

Monday: In Health & Science, surgeons do intricate heart surgery using a robot's steady hands.

Don Drake's e-mail address is ddrake@phillynews.com

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