Percutaneous coronary intervention overview

Percutaneous coronary intervention Microchapters
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Patient Information
Overview
Risk Stratification and Benefits of PCI
Preparation of the Patient for PCI
Equipment Used During PCI
Pharmacotherapy to Support PCI
Vascular Closure Devices
Recommendations for Perioperative Management–Timing of Elective Noncardiac Surgery in Patients Treated With PCI and DAPT
Post-PCI Management
Risk Reduction After PCI
Post-PCI follow up
Hybrid coronary revascularization
PCI approaches
PCI Complications
Factors Associated with Complications Vessel Perforation Dissection Distal Embolization No-reflow Coronary Vasospasm Abrupt Closure Access Site Complications Peri-procedure Bleeding Restenosis Renal Failure Thrombocytopenia Late Acquired Stent Malapposition Loss of Side Branch Multiple Complications
PCI in Specific Patients
Cardiogenic Shock Left Main Coronary Artery Disease Refractory Ventricular Arrhythmia Severely Depressed Ventricular Function Sole Remaining Conduit Unprotected Left Main Patient Adjuncts for High Risk PCI
PCI in Specific Lesion Types
Classification of the Lesion The Calcified Lesion The Ostial Lesion The Angulated or Tortuous Lesion The Bifurcation Lesion The Long Lesion The Bridge Lesion Vasospasm The Chronic Total Occlusion The Left Internal Mammary Artery Multivessel Disease Distal Anastomotic Lesions Left Main Intervention The Thrombotic Lesion
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Percutaneous coronary intervention (PCI), commonly known as coronary angioplasty, is an invasive cardiologic therapeutic procedure to treat the stenotic (narrowed) coronary arteries of the heart. These stenotic segments are due to the build up of cholesterol-laden plaques that form due to atherosclerosis in coronary heart disease. PCI is usually performed by an interventional cardiologist. Percutaneous coronary intervention can be performed to reduce or eliminate the symptoms of coronary artery disease, including angina (chest pain), dyspnea (shortness of breath) on exertion, and congestive heart failure. PCI is also used to abort an acute myocardial infarction, and in some specific cases it may reduce mortality.

Risks stratification and benefits of PCI

There are several risk assessment scores which can help in determining a patient's risk for death, myocardial infarction and recurrent cardiac events.

Preparation of the patient for PCI

There are several steps involved in preparing the patient for PCI, which include the use of premedications and the use of a Heart Team approach. Attention should be given to possible adverse reactions to contrast, possible anaphylactoid reactions, the use of statins, bleeding risk in the patient, and the presence of on-site surgical back-up services.

PCI equipment

Guiding catheter selection

Diagnostic catheters used for coronary arteriography are usually constructed from polyethylene or polyurethane with a fine wire braid within the wall to allow advancement and directional control (torquability) and to prevent kinking. The outer diameter size of the catheters ranges from 4 to 8F, but 5 and 6F catheters are used most commonly for diagnostic arteriography.

Guidewire selection

Angioplasty guidewires are small, soft, flexible, lubricated, wires that act as a rail over which equipment such as an angioplasty balloon, a stent, or an intravascular ultrasound device can be delivered over into the coronary artery. Angioplasty guide wires were introduced in 1982 by doctors Simpson and Roberts. The introduction of coronary guidewires was a major advance as it allowed the angioplasty balloon to be a traumatically steered to the proper location.

Pharmacotherapy to Support PCI

2011 AHA guidelines recommend the use of antiplatelet therapy aspirin (Level of Evidence: B) and P2Y12 receptor inhibitor (clopidogrel, prasugrel and ticagrelor) (Level of Evidence: A) to support PCI in patients with ACS. Few randomised trials have been conducted showing comparison of clopidogrel with aspirin and other P2Y12 inhibitors (prasugrel and ticagrelor) in terms of clinical benefit and risk of bleeding when given in patients undergoing PCI. However, there is limited data comparing new P2Y12 receptor inhibitors (prasugrel and ticagrelor) for downstream and upstream therapy in patients undergoing PCI with non ST elevation MI in terms of clinical benefit and adverse effects. Hence, a new large scale randomised open label trial called DUBIUS is in process in Italy comparing two new P2Y12 inhibitors prasugrel and ticagrelor for pretreatment in patients with non ST elevation MI undergoing PCI.