Staged PCI
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Synonyms and keywords: delayed PCI
Overview
Staged PCI or delayed PCI is referred to the performance of a percutaneous coronary intervention (PCI) at a later date separate from the performance of the diagnostic catheterization or the performance of an initial PCI. Ad hoc PCI is defined as performance of the PCI procedure immediately following diagnostic catheterization [1]. Same day PCI is defined as removing the patient from the cardiac catheterization laboratory following the procedure, and then performing the PCI procedure later in the day. Databases usually do not allow a distinction between "Ad hoc PCI" and "Same day PCI". As a result there is no data regarding the prevalence or the impact of same day PCI.
Historical Perspective
When PCI was first developed, the risk of requiring urgent coronary artery bypass grafting (CABG) surgery was approximately 5%, and this necessitated the availability of onsite CABG. AS PCI became safer and more predictable, it was more frequently performed immediately following the diagnostic cardiac catheterization ("ad hoc PCI").
Advantages of Staged PCI
More detailed informed consent can be provided regarding the proposed revascularization procedure and the potential alternatives such as CABG. Patients who are at risk of contrast induced acute tubular necrosis (patients over age 65, patients with diabetes, patients with impaired renal function), may benefit from a staged PCI procedure by minimizing the dye load required during two separate procedures.
Risk Factors for Contrast Induced Nephropathy
Three factors have been associated with an increased risk of contrast-induced nephropathy: pre-existing renal insufficiency (such as Creatinine clearance < 60 mL/min [1.00 mL/s] - online calculator), pre-existing diabetes, and reduced intravascular volume.[2][3] A clinical prediction rule is available to estimate probability of nephropathy (increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h)[4] based upon the following risk factors:
- Systolic blood pressure <80 mm Hg - 5 points
- Intraarterial balloon pump - 5 points
- Congestive heart failure (Class III-IV or history of pulmonary edema) - 5 points
- Age >75 y - 4 points
- Hematocrit level <39% for men and <35% for women - 3 points
- Diabetes - 3 points
- Contrast media volume - 1 point for each 100 mL
- Renal insufficiency:
- Serum creatinine level >1.5 g/dL - 4 points OR
- Estimated Glomerular filtration rate (online calculator)
- 2 for 40–60 mL/min/1.73 m2
- 4 for 20–40 mL/min/1.73 m2
- 6 for < 20 mL/min/1.73 m2
Scoring:
5 or less points
- Risk of CIN - 7.5
- Risk of Dialysis - 0.04%
6–10 points
- Risk of CIN - 14.0
- Risk of Dialysis - 0.12%
11–16 points
- Risk of CIN - 26.1*
- Risk of Dialysis - 1.09%
>16 points
- Risk of CIN - 57.3
- Risk of Dialysis - 12.8%
Guidelines Regarding Staged PCI
Performance of PCI in a non-culprit artery at the time of a ST elevation MI (STEMI) is a class III contraindication. Only 2% of interventional cardiologist would perform a PCI in a non-culprit vessel in the setting of STEMI in a patient who is hemodynamically stable [5]. The need for and the timing of staged PCI among patients with unstable angina (UA) or non ST elevation MI (NSTEMI) and stable angina is less clear.
Timing of a Staged PCI
STEMI
62% of interventional cardiologists recommend that the PCI of the non-culprit artery be performed more than 15 days after the STEMI [6].
UA / NSTEMI
There is less of a consensus regarding the optimal timing of a staged PCI among UA / NSTEMI patients. 55% of surveyed cardiologists recommend waiting > 2 weeks following the initial revascularization to perform the next PCI, while 22% recommended that the additional PCI be performed during the same hospitalization as the initial revascularization.
Stable Angina
Among patients with stable angina, 64% of surveyed cardiologist recommend waiting ≥ 15 days to perform the second PCI following the initial revascularization while 35% recommend performance of PCI within 2 weeks of the initial revascularization.
Reasons Cited by Interventional Cardiologists to Perform a Staged PCI
In descending order of importance, the following reasons were offered as reasons for staging a procedure in a survey of interventional cardiologists [7]:
- Renal function
- Accumulated contrast use
- Lesion complexity
- Presentation with acute coronary syndrome
- Symptomatology
- Cumulative fluoroscopy dose
References
- ↑ Ad Hoc Percutaneous Coronary Intervention: A Consensus Statement From the Society for Cardiovascular Angiography and Interventions http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CDkQFjAB&url=http%3A%2F%2Fwww.scai.org%2Fasset.axd%3Fid%3Dc985cb20-a31b-4e82-a688-2f82be854b21&ei=FD7KUMXwKKay0AHEp4CACg&usg=AFQjCNH2rTxEcgSgaigX_lYvSvML2u7E-A&bvm=bv.1355272958,d.dmQ
- ↑ McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW (1997). "Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality". Am J Med. 103 (5): 368–75. PMID 9375704.
- ↑ Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, Legako RD, Leon DF, Murray JA, Nissen SE, Pepine CJ, Watson RM, Ritchie JL, Gibbons RJ, Cheitlin MD, Gardner TJ, Garson A Jr, Russell RO Jr, Ryan TJ, Smith SC Jr (1999). "ACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions". J Am Coll Cardiol. 33 (6): 1756–824. PMID 10334456.
- ↑ Mehran R, Aymong ED, Nikolsky E; et al. (2004). "A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation". J. Am. Coll. Cardiol. 44 (7): 1393–9. doi:10.1016/j.jacc.2004.06.068. PMID 15464318.
- ↑ http://interventions.onlinejacc.org/article.aspx?articleid=1112023
- ↑ http://interventions.onlinejacc.org/article.aspx?articleid=1112023
- ↑ http://interventions.onlinejacc.org/article.aspx?articleid=1112023