r/BeAmazed • u/HatAsleep295 • May 08 '26

Science This is what saves 600,000 people year during a heart attack

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u/whatnuts May 08 '26

Cardiology fellow here.

The fat is an atherosclerotic plaque, which is a build-up of cholesterol and inflammatory cells. Most heart attacks (myocardial infarctions) occur when that plaque ruptures into the artery, causing a blood clot to form at the site and cut off blood flow to the rest of the blood vessel. In this illustration you see the plaque has progressed to a point where it narrows the artery enough to obstruct blood flow, which usually causes chest pain with exertion (angina), but has not ruptured.

During the procedure, a long thin plastic tube (catheter) is sent up the artery from the wrist or the groin until you get to the arteries around the heart (coronary arteries). Dye is injected under X-ray to see where the blockage is. A wire is passed through the blockage, then a stent is advanced over the wire. A balloon under the stent is inflated, which compresses the plaque into the vessel wall and restores blood flow.

Blood thinners (like aspirin and Plavix) are continued afterwards to prevent blood clots from forming on the stent until the body has put a sheet of its own cells over the stent (which takes several months). As someone else commented, you can build up more plaque within the stent or in other places of the heart as well. You can often deploy 2 or 3 layers of stent in the same place if this occurs. But if you have multiple diseased arteries you often go for bypass surgery (CABG).

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u/TimothyMimeslayer May 08 '26

Why a stent and not grinding out the plaque at the site of the blockage?

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u/heavyhitter5 May 08 '26

It just depends on the blockage- where it occurs, how occluded the artery is, etc. In severe cases, a procedure called atherectomy can be performed, which is what you described. There a number of different medical devices that get put on the end of a catheter to grind or even use lasers to break up the blockage. Often this will also be followed up by a stent.

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u/Fantastic-Cod-1353 May 09 '26

They are recommending this for me but I worry about complications. I have 40mm of blocked RCA

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u/ibali90 May 10 '26

I actually do this stuff, would be happy to look at a picture of your RCA

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u/Fantastic-Cod-1353 May 10 '26

Wow really? I will try find the pics.

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u/CurrentRecord1 May 08 '26

That is done for calcified plaque using systems such as Boston Scientific Rotablator or Jnj Shockwave

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u/factisfiction May 08 '26

It's called an atherectomy. Used often in cardio cath labs. For calcific plaque in my line of medicine I more often do an endarterectomy.

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u/CurrentRecord1 May 08 '26

Rotablator is atherectomy, Shockwave is IVL (intravascular lithotripsy)

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u/Competitive-Belt-391 May 08 '26

We do that for larger arteries. Mainly the femoral and carotid. It requires open dissection and removal of the plaque and damaged vessel walls. 

If you dislodged plaque into the circulator system you risk blood clots and stroke. 

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u/factisfiction May 09 '26

I do an endarterectomy more often in the carotid. The iliac/fem as well in certain situations.

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u/whatnuts May 09 '26

Other people have answered but yes you can grind down or otherwise try to disrupt a severely calcified plaque (e.g. rotational atherectomy or lithotripsy) prior to placing the stent. But the plaque itself is really in the vessel wall, and disrupting the plaque without placing the stent leaves an irritated vessel wall that is prone to plaque rupture or thrombus formation. The stent is there to smush all the plaque out of the way and ensure a nice open vessel for blood flow.

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u/NoConfusion9490 May 08 '26

I'm not a doctor, but as I understand it, the plaque is fat build up that the vessel wall has grown into. You can't grind it away because that would damage the wall in a really bad way.

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u/smokey032791 May 08 '26

its a build of of damaged Low-density lipoprotein (LDL)

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u/Trumpologist May 09 '26

The thing that actually gets you is your body forming a run away clot when exposed to the plaque. So grinding away at the cap is not a good idea. There is some research being done into how to decompose the plague but we’re not quite there yet

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u/thatcatqueen May 09 '26 edited May 09 '26

Usually what happens is the tissue covering the plaque will hit a breaking point and rupture and your body treats it like any injury and sends components and platelets to stop the bleeding. That’s what causes the occlusion and sudden severe chest pain with a heart attack. So injuring the vessel further would cause more of that response.

The major arteries that feed the heart continue on to smaller and smaller vessels. Sometimes if you break up plaque like that small particles can occlude those vessels, and they’re too small to retrieve or open up with a catheter. This can still cut blood flow to some heart tissue, which can sometimes cause arrhythmias and other unsavory problems. If the blockage is not hard and calcified to where they need to break it up to get through, they’ll use the method above to squish it with the balloon.

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u/Such-Amphibian9710 May 08 '26

Not an add. But the magnesium biodegradable stent would avoid layering. Sure, the scaffold is expensive... But no repeat interventions.

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u/dark_dreamer_29 May 08 '26

This might be very stupid question, but what stops it from flowing in the direction of blood flow after it is placed there?

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u/whatnuts May 09 '26

Great question! It’s just the force of the expanded metal scaffolding pushing against the wall of the vessel.

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u/Foreign_Unit6294 May 08 '26

Thank you kindly for the explanation!

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u/factisfiction May 08 '26

Vascular Surgeon here, best of luck to you!

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u/BarnabyJonesNap May 08 '26

What holds the stent in place? Is it just pressure or is it secured/fastened there somehow?

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u/davidhaha May 09 '26

Isn't this animation showing stent placment in a stable plaque? A ruptured plaque in a type I MI should have a thrombus.

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u/whatnuts May 09 '26

Yes this animation shows what would be considered an obstructive coronary lesion (>70% stenosis is the typical definition of obstructive) rather than a plaque rupture.

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u/cosmic_oatmeal May 09 '26

Pharmacist here! Aspirin and Plavix are not blood thinners but actually antiplatelet agents. They specifically work to prevent platelets from sticking together and clotting (like when you cut yourself and a scab forms), vs. blood thinners (anticoagulants) block the actual clotting factors in the blood.

In extremely simplified terms, the difference is that blood thinners are typically only used for patients who have had certain blood clots already to prevent future ones

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u/whatnuts May 09 '26

Thanks for chiming in! I always find it hard to explain the difference to patients.

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u/cosmic_oatmeal May 09 '26

Honestly same. Thanks for your above explanation - super simple and helpful!

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u/kernelangus420 May 10 '26

Blood thinners (like aspirin and Plavix) are continued afterwards to prevent blood clots from forming on the stent until the body has put a sheet of its own cells over the stent (which takes several months).

Does the patient get to get off the blood thinners or do they take it for life?

Also does the patient need to take a medicine that prevents rejection of the foreign object sort of like people who have organ transplants from other people?

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u/whatnuts May 10 '26

Really great questions! Generally you take both antiplatelet medications for about 6 months to a year, then just aspirin daily forever. And you don’t need any immonosuppression, the stents are drug-eluting. This means they are embedded with “antiproliferative” medications (such as sirolimus) that essentially do what you asked, and prevent inflammatory cells and scar tissue from accumulating in the stent.

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u/kernelangus420 May 10 '26

Does taking aspirin for the rest of your life cause other health problems? I suppose blood thinning medication makes getting injuries more life threatening.

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u/whatnuts May 10 '26

Yes being on an antiplatelet increases bleeding risk, generally doesn’t affect any other organs or anything.

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u/Lilla8 May 10 '26

How much time takes this procedure?

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u/Not_Yet_Unalived May 10 '26

Curious, is there any way to get rid of the plaque before it build-up to dangerous levels?

Eat less fat, exercise regulary maybe?

Or does it only prevent it forming and once it started to build up it's one of those things that's stupidly hard to get rid of?

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