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Stents are expandable metal or plastic tube inserted into the lumen of an anatomic vessel or duct to keep the passageway open, and stenting is the placement of a stent. There is a wide variety of stents used for different purposes, from expandable coronary, vascular and biliary stents, to simple plastic stents used to allow the flow of urine between kidney and bladder. Why would I need a stent?
Stents are usually needed when plaque blocks a blood vessel. Plaque is made of cholesterol and other substances that attach to the walls of a vessel.
You may need a stent during an emergency procedure. An emergency procedure is more common if an artery of the heart called a coronary artery is blocked. Your doctor will first place a catheter into the blocked coronary artery. This will allow them to do a balloon angioplasty to open the blockage. They’ll then place a stent in the artery to keep the vessel open.
Stents can also be useful to prevent aneurysms from rupturing in your brain, aorta, or other blood vessels.
Besides blood vessels, stents can open any of the following passageways:
• bile ducts, which are tubes that carry bile to and from digestive organs
• bronchi, which are small airways in the lungs
• ureters, which are tubes that carry urine from the kidneys to the bladder
These tubes can become blocked or damaged just like blood vessels can.
How Are Stents Used?
For the Coronary Arteries
Doctors may use stents to treat coronary heart disease (CHD). CHD is a disease in which a waxy substance called plaque builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood.
When plaque builds up in the arteries, the condition is called atherosclerosis.
Plaque narrows the coronary arteries, reducing the flow of oxygen-rich blood to your heart. This can lead to chest pain or discomfort called angina.
The buildup of plaque also makes it more likely that blood clots will form in your coronary arteries. If blood clots block a coronary artery, a heart attack will occur.
Doctors may use percutaneous coronary intervention (PCI), also known as coronary angioplasty, and stents to treat CHD. During PCI, a thin, flexible tube with a balloon or other device on the end is threaded through a blood vessel to the narrow or blocked coronary artery.
Once in place, the balloon is inflated to compress the plaque against the wall of the artery. This restores blood flow through the artery, which reduces angina and other CHD symptoms.
Unless an artery is too small, a stent usually is placed in the treated portion of the artery during PCI. The stent supports the artery's inner wall. It also reduces the chance that the artery will become narrow or blocked again. A stent also can support an artery that was torn or injured during PCI.
Even with a stent, there's about a 10–20 percent chance that an artery will become narrow or blocked again in the first year after PCI. When a stent isn't used, the risk can be as much as 10 times as high. Research has shown that as time goes by, people who have coronary artery stents are in less danger of risks from the surgery but more prone to the risks of chronic diseases, such as type 2 diabetes and renal failure.
For the Carotid Arteries
Doctors also may use stents to treat carotid artery disease. This is a disease in which plaque builds up in the arteries that run along each side of your neck. These arteries, called carotid arteries, supply oxygen-rich blood to your brain.
The buildup of plaque in the carotid arteries limits blood flow to your brain and puts you at risk for a stroke.
Doctors use stents to help support the carotid arteries after they're widened with PCI. Researchers continue to explore the risks and benefits of carotid artery stenting.
For Other Arteries
Plaque also can narrow other arteries, such as those in the kidneys and limbs. Narrow kidney arteries can affect kidney function and lead to severe high blood pressure.
Narrow arteries in the limbs, a condition called peripheral artery disease (P.A.D.), can cause pain and cramping in the affected arm or leg. Severe narrowing can completely cut off blood flow to a limb, which could require surgery.
To relieve these problems, doctors may do PCI on a narrow kidney, arm, or leg artery. They often will place a stent in the affected artery during the procedure. The stent helps support the artery and keep it open.
For the Aorta in the Abdomen or Chest
The aorta is a major artery that carries oxygen-rich blood from the left side of the heart to the body. This artery runs through the chest and down into the abdomen.
Over time, some areas of the aorta's walls can weaken. These weak areas can cause a bulge in the artery called an aneurysm. An aneurysm in the aorta can burst, leading to serious internal bleeding. When aneurysms occur, they're usually in the abdominal aorta.
To help avoid a burst, doctors may place a fabric stent in the weak area of the abdominal aorta. The stent creates a stronger inner lining for the artery.
Aneurysms also can develop in the part of the aorta that runs through the chest. Doctors also use stents to treat these aneurysms. How well the stents work over the long term still isn't known.
To Close Off Aortic Tears
Another problem that can occur in the aorta is a tear in its inner wall. If blood is forced into the tear, it will widen.
The tear can reduce blood flow to the tissues that the aorta serves. Over time, the tear can block blood flow through the artery or burst. If this happens, it usually occurs in the chest portion of the aorta.
Researchers are developing and testing new kinds of stents that will prevent blood from flowing into aortic tears. A stent placed within the torn area of the aorta might help restore normal blood flow and reduce the risk of a burst aorta.
How is a stent performed?
There are several ways to insert a stent.
Your doctor usually inserts a stent using a minimally invasive procedure. They will make a small incision and use a catheter to guide specialized tools through your blood vessels to reach the area that needs a stent. This incision is usually in the groin or arm. One of those tools may have a camera on the end to help your doctor guide the stent.
During the procedure, your doctor may also use an imaging technique called an angiogram to help guide the stent through the vessel.
Using the necessary tools, your doctor will locate the broken or blocked vessel and install the stent. Then they will remove the instruments from your body and close the incision.
What To Expect After a Stent Procedure
After either type of stent procedure (for arteries narrowed by plaque or aortic aneurysms), your doctor will remove the catheter from your artery. The site where the catheter was inserted will be bandaged.
A small sandbag or other type of weight may be put on top of the bandage to apply pressure and help prevent bleeding. You'll recover in a special care area, where your movement will be limited.
While you're in recovery, a nurse will check your heart rate and blood pressure regularly. The nurse also will look to see whether you're bleeding from the insertion site.
Eventually, a small bruise and sometimes a small, hard "knot" will appear at the insertion site. This area may feel sore or tender for about a week.
You should let your doctor know if:
• You have a constant or large amount of bleeding at the insertion site that can't be stopped with a small bandage
• You have any unusual pain, swelling, redness, or other signs of infection at or near the insertion site
Common Precautions After a Stent Procedure
BLOOD CLOTTING PRECAUTIONS
After a stent procedure, your doctor will likely recommend that you take aspirin and another anticlotting medicine. These medicines help prevent blood clots from forming in the stent. A blood clot can lead to a heart attack, stroke, or other serious problems.
If you have a metal stent, your doctor may recommend aspirin and another anticlotting medicine for at least 1 month. If your stent is coated with medicine, your doctor may recommend aspirin and another anticlotting medicine for 12 months or more. Your doctor will work with you to decide the best course of treatment.
Your risk of blood clots significantly increases if you stop taking the anticlotting medicine too early. Taking these medicines for as long as your doctor recommends is important. He or she may recommend lifelong treatment with aspirin.
If you're considering surgery for some other reason while you're on these medicines, talk to your doctor about whether it can wait until after you've stopped the medicine. Anticlotting medicines may increase the risk of bleeding.
Also, anticlotting medicines can cause side effects, such as an allergic rash. Talk to your doctor about how to reduce the risk of these side effects.
You should avoid vigorous exercise and heavy lifting for a short time after the stent procedure. Your doctor will let you know when you can go back to your normal activities.
Metal detectors used in airports and other screening areas don't affect stents. Your stent shouldn't cause metal detectors to go off.
If you have an aortic fabric stent, your doctor will likely recommend followup imaging tests (for example, chest x ray) within the first year of having the procedure. After the first year, he or she may recommend yearly imaging tests.
Stents help prevent arteries from becoming narrow or blocked again in the months or years after percutaneous coronary intervention (PCI), also known as coronary angioplasty. However, stents aren't a cure for atherosclerosis or its risk factors.
Making lifestyle changes can help prevent plaque from building up in your arteries again. Talk with your doctor about your risk factors for atherosclerosis and the lifestyle changes you'll need to make.
Lifestyle changes may include changing your diet, quitting smoking, being physically active, losing weight, and reducing stress. You also should take all medicines as your doctor prescribes. Your doctor may suggest taking statins, which are medicines that lower blood cholesterol levels.
What medications will I need to take after a stent procedure?
You will need to take one or more antiplatelet agents. These medicines keep platelets from clumping together and forming blood clots in the stent and blocking the artery.
One antiplatelet agent is aspirin. A second type is called a P2Y12 inhibitor. You may be prescribed one of three P2Y12 inhibitors -- clopidogrel, prasugrel, or ticagrelor. Which one of these medications your doctor prescribes will be based on what he or she feels is best for you, based on your risk of blood clots and bleeding. When aspirin and a P2Y12 inhibitor are used together it is called dual antiplatelet therapy (DAPT).
In addition to DAPT, you may be prescribed additional medications as well.
How long do I have to take these medications?
Aspirin is used indefinitely. How long you need to take a P2Y12 inhibitor depends on why you are being prescribed the drug, as well as your future risk of blood clots and bleeding.
• If you had a heart attack, the general recommendation is that you should be on a P2Y12 inhibitor for at least a year. If you don’t have a high bleeding risk, longer duration of therapy may be beneficial and lower your risk of future heart attack.
• If you are a high bleeding risk, you may have been treated with a bare metal stent. In this case, you should take a P2Y12 inhibitor for at least one month.
• If you were treated with a drug-eluting stent, in general, you will be treated for at least 6-12 months with a P2Y12 inhibitor. If you are at a higher bleeding risk, you may be treated for a shorter period of time (3-6 months). If you don’t have a high bleeding risk, longer duration of therapy (more than 6-12 months) may be beneficial and lead to a lower risk of future heart attack and clotting of the stent.
It is important for you to take your medication as prescribed. Stopping it on your own can lead to a marked increase in risk of clots forming inside the stent, particularly in the first month or months after stent placement.
What are the complications associated with inserting a stent?
Any surgical procedure carries risks. Inserting a stent may require accessing arteries of the heart or brain. This leads to an increased risk of adverse effects.
The risks associated with stenting include:
• an allergic reaction to medications or dyes used in the procedure
• breathing problems due to anesthesia or using a stent in the bronchi
• a blockage of the artery
• blood clots
• a heart attack
• an infection of the vessel
• kidney stones due to using a stent in the ureters
• a re-narrowing of the artery
Rare side effects include strokes and seizures.
Few complications have been reported with stents, but there’s a slight chance the body will reject the stent. This risk should be discussed with your doctor. Stents have metal components, and some people are allergic or sensitive to metals. Stent manufacturers recommend that if anyone has a sensitivity to metal, they should not receive a stent. Speak with your doctor for more information.
If you have bleeding issues, you will need to be evaluated by your doctor. In general, you should discuss these issues with your doctor. They can give you the most current information related to your personal concerns.
More often than not, the risks of not getting a stent outweigh the risks associated with getting one. Limited blood flow or blocked vessels can create serious and deadly consequences.