Saves thousands of lives as a matter of routine

​Since its introduction 30 years ago, percutaneous coronary intervention (PCI) has changed from being a nerve-racking journey into unknown territory to an everyday procedure. However, there is a reverse side to this successful, now routine procedure.

"Heart failure" is the cry when a builder collapses on a street in Copenhagen on a hot summer morning at 7.15. Slowly over the years, the blood vessel along the 50-year-oldish man's heart had become clogged and finally closed completely, resulting in heart failure. 

An ambulance and a response vehicle are summoned, and with shocks from a defibrillator, the paramedics manage to resuscitate the man. About 30 minutes after calling the emergency services, the builder is on the operating table at 7.50. 

Information about the patient is sent from the ambulance to the hospital staff, so they are well prepared for his arrival. 

Through a tiny two-millimetre hole in the man's groin, Steffen Helqvist, the consultant, probes into the major artery system and reaches the blood clot, sucks it out, and the so-called stent – a sort of woven metal tube –  is inserted and expanded using a balloon to keep the passageway of the vessel open. The patient is scanned regularly, so that Steffen Helqvist can monitor his patient and see exactly what he is doing. Twenty-five minutes later, the patient is moved to the recovery room and the operation is successfully completed.

A journey into unknown territory

The quick - and life-saving - operation in less than half-an-hour is a sharp contrast to a similar situation 30 years ago, when physicians at Rigshospitalet performed this type of surgery for the first time in March 1989.

"This was completely new and unknown territory. A team was ready to perform the PCI in one room, and another team was ready in the next room to cut open the chest and perform open heart surgery in case the PCI went wrong," said Professor Thomas Engstrøm, a consultant from the Department of Cardiology.

Ten years earlier, there was not much that could be done for a blood clot patient at all.

"We gave them laxatives to prevent them from over exerting themselves and we kept them in bed. Almost half of them died within a year," said Thomas Engstrøm.

Then came clot-dissolving drugs, although they were not as effective as balloon angioplasty. Thomas Engstrøm estimates that 35,000-40,000 balloon angioplasties have been performed since 1989. Survival and success rates have taken a giant leap forward.

"Before we knew how to insert stents, 40% of the patients returned within one year for an additional procedure, this number fell to just 20% after the stent was introduced. But the vascular wall can become irritated and form scar tissue due to the metal. We therefore began coating the stent with a preventive drug, which has reduced the number of patients returning with this problem to 4-5%," said Thomas Engstrøm.

An amazing collaboration

This treatment is much more gentle for the patient than open heart surgery, and it has had a staggering success rate. And even though – as with all surgery – there are risks, there are only very few. 

"The vessel can burst when the balloon is blown up, and this can be critical for the patient. If blood runs into the pericardium it takes up space and may result in circulatory failure. Material may come loose and get caught in the brain, but this is very rare today," said Thomas Engstrøm.

The greatest risk for a blood clot patient is the time in which the artery is closed and, in the worst case, if the heart stops.

"If the heart stops beating, the oxygen supply to the brain will stop, and if the heart doesn’t start beating again quickly, this may cause serious damage to the brain," said Thomas Engstrøm.

In addition to many scheduled treatments, Rigshospitalet performs four-five acute PCIs on average every day, and by far the majority of them have a successful outcome.

Huge benefits backfire

"This is the result of an amazing collaboration between engineers, dedicated physicians, pre-hospital units and politicians who have created a system that provides quick and effective treatment in Denmark," said Thomas Engstrøm.

"Today, a man who has collapsed due to something that he would've died from 30 years earlier can be sitting and drinking a cup of coffee in the recovery room only an hour after surgery," said Thomas Engstrøm.

But actually it is not all good. There is a reverse side to the high success rate.

"The positive development has become a paradox. Some patients receive pain-free treatment so quickly that they don't feel that they've been sick. It can be difficult to convince them not to smoke, to watch their weight and to exercise. I've had patients who expect to go home and attend a meeting the next day," said the consultant.

The balloon blows life into the blood vessel

  • A PCI is used when a blood vessel is clogged.

  • The surgeon inserts a stent into the blood vessel. This is a woven metal tube that is expanded using a balloon.

  • The stent can be enlarged by blowing up the balloon, and is designed so that it will not collapse when the balloon is removed.

  • The blood can now run freely through the previously narrowed blood vessel.

Blood clots are often related to lifestyle

  • Blood clots are often related to an unhealthy lifestyle.
  • Diet, high cholesterol levels, high blood pressure and diabetes, and especially smoking, are often risk factors.
  • Men are particularly at risk – this is also because they consult a doctor late or not at all when they experience symptoms.

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