Central  South  Dakota  Medical News
The Clinical View
by Phillip Hoffsten
15 September 2004

WHAT IS A BLOOD VESSEL STENT?

     The gentleman was 66-years old and was a retired executive who moved to South Dakota to be near family.  He had been a hard-driving individual for over 40 years with the same company in California. He also had multiple risk factors that predisposed him to heart artery problems in addition to stroke problems.  Prior to leaving California three years ago, he had a temporary paralysis on his right side.  This had happened at work and he was taken to the emergency room at the local hospital where he was found to have a significant block in the left carotid artery that supplied his brain.  Fortunately, his function returned and the artery was treated surgically to get rid of the block.  He had not seen a doctor in the previous 15 years and was warned by his HMO physicians at that time that he needed further medical attention to check his heart.  He declined that advice thinking that he would get it checked when he moved to South Dakota.  With the classical male concept of invincibility, he moved to South Dakota with no intention of seeing a doctor when he got here.

     Fate intervened again and now he came to the emergency room with chest pain and difficulty breathing.  He was diagnosed as having a heart attack and given clot-melting medicine to open an artery that supplied his heart.  He was then flown to Rapid City where the heart doctors blew up a tiny balloon in the area where his heart artery was blocked.  They put a “stent” at that site to keep the artery open.  His heart attack problem was dealt with and I met him for the first time in follow up after the stent had been placed.

     He was a very sophisticated individual that knew a lot about airplanes that he had worked on for forty years but he didn’t know anything about health.  In his mind, health was something that he was entitled to naturally.  The idea that now he had a piece of plastic in one of his heart arteries and needed to take medicine blew his mind.  This just wasn’t natural. I could see I had a lot of explaining to do.

     I first inquired with him about how airplanes are maintained.  He acknowledged that they needed to carefully gone over with extensive safety checks on a scheduled basis.  He pointed out that this was part of the excellent safety record that the passenger airline industry had established over many years.  I applauded his efforts and then asked why he thought people would be different than airplanes, for which he really didn’t have an answer.  I explained that arteries in the body get stopped up in relation to the person having high blood pressures such as this gentleman had for many years, plus adding high cholesterol which he had had for many years, and for smoking cigarettes which he had done for 50 years.  Although the most advertised problem with these risk factors is heart disease, they also affect all the arteries in the body including those of the brain, kidneys and the legs.  We don’t really understand the reasons these risk factors lead to the arteries developing hourglass-like constrictions that impair the blood flow through the artery.  Eventually the constriction gets small enough that it shuts off all together and then the organ supplied by that artery dies.  If the artery supplies the brain, it is called a stroke.  If it supplies the heart, it is called a heart attack or if it supplies the kidney, the kidney dies.  If the blood vessel supplies the legs, one can wind up with an amputation of the leg.  He wanted to know what could be done to prevent the problem at this point.

     I explained to him that stents were tiny plastic springs or steel springs covered with plastic.  In order to place them in the artery where a constriction has occurred, the spring first had to be wound very tightly, slid into place in the artery constriction and then the tight winding released.  The spring then opens and provides a mechanical device to keep the artery from closing off again.  These devices can now be placed in the heart, the kidneys or the legs to re-establish blood flow to these organs.  They are placed in an operating room through a catheter that is threaded into the big artery in the groin.  The spring is then manipulated up through the major aorta to the heart and then slipped downstream into the heart artery where the spring is released and opens up in the artery.  Once placed, that spring is there to stay.

     He wanted to know why he needed to take medication now that he had never taken any before.  I told him that the basic problem represented blood clots that could form on the spring once it was placed.  That spring is a foreign surface upon which platelets will stick and can grow a clot right inside the spring.  If something isn’t done to prevent that, the spring will clot off and cause the same heart attack that it was designed to prevent.  So the person needs to take a drug called Plavix which unfortunately is quite expensive.  This drug prevents platelets from sticking to the spring and clotting it off.  It is usually required for about six weeks to three months until the body grows a new blood vessel surface over the spring and buries it forever.  Once the spring is “epithelialized” the risk of clotting is much, much less and Plavix can be stopped.  Epithelialized simply means that the blood vessel is growing a new natural surface over the spring.

     Nothing is ever simple and that applies to stents also.  The first stents used unfortunately caused irritation in some people and tissue would scar up at each end of the stent and block it off, causing the same problem that it was designed to prevent.  Modern stents now have a chemical incorporated into the stent plastic that prevents this scarring and thereby keeping the blood vessel open.  What I am describing here in a few paragraphs has taken 20 years of research and painful experience to reach our present level of competence which these stents.  Originally, stents were  used for blockages of the arteries in the heart. Now they are used for blockages in those arteries that supple the legs and the kidneys and more recently are being used to open the arteries that supply the blood vessels to the brain.  Placing these stents is a highly specialized skill done in major medical centers such as Sioux Falls or Rapid City.

     Once the stent is placed, it is just like an airplane.  It needs to be maintained so that it doesn’t close off.  I explained this to the gentleman above and pointed out to him that he needed to be a little kinder to his body to prevent further problems and the need for further stents in any of the arteries in his body.  He finally agreed to take a medicine for blood pressure and a medicine for cholesterol, in addition to the Plavix that he was already on.  With a relatively minor effort, he stopped his cigarettes.  He said it wasn’t nearly as hard as he thought it was going to be.

     That was two years ago and he seems to be enjoying his retirement at this point.  I keep urging these men that I see to take at least as good of care of their bodies as they do of their trucks or their tractors or their airplanes or their cars.  They would never think of neglecting maintenance on their vehicle for 15 years but will neglect themselves at least that long.  The healthcare professionals at your local clinic, given the chance, can help men or women avoid needing to know what a stent even is.  We don’t put the stents in but we do know how to take care of them the same way that your local maintenance people know how to take care of an airplane or a car even though we don’t make them in central South Dakota.