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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [21] ; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [22]
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 coronary heart disease .
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 .
Epidemiology and Demographics Approximately 850,000 PCIs are performed each year in the United States. 2011 ACCF/AHA/SCAI Guideline Recommendations: CAD Revascularization [ 1] ACCF/AHA Guidelines for Heart Team Approach to Revascularization Decisions[ 1] ACCF/AHA Guidelines for Revascularization to Improve Survival: Left Main Coronary Artery Disease[ 1] ACCF/AHA Guidelines for Revascularization to Improve Survival: Non-Left Main Coronary Artery Disease[ 1] ACCF/AHA Guidelines for Revascularization to Improve Symptoms[ 1] ACCF/AHA Guidelines for Clinical factors that may influence the choice of revascularization: Dual Antiplatelet Therapy Compliance and Stent Thrombosis[ 1] 2011 ACCF/AHA/SCAI Guideline Recommendations: Pre-procedural Considerations [ 1] ACCF/AHA Guidelines for Contrast-Induced Acute Kidney Injury[ 1] ACCF/AHA Guidelines for Statin Treatment[ 1] ACCF/AHA Guidelines from Bleeding Risk[ 1] ACCF/AHA Guidelines for Role of Onsite Surgical Backup[ 1]
Class III (Harm)
"1. Primary or elective PCI should not be performed in hospitals without on-site cardiac surgery capabilities without a proven plan for rapid transport to a cardiac surgery operating room in a nearby hospital or without appropriate hemodynamic support capability for transfer. (Level of Evidence: C ) "
Class IIa
"1. Primary PCI is reasonable in hospitals without on-site cardiac surgery, provided that appropriate planning for program development has been accomplished.[ 105] [ 106] (Level of Evidence: B ) "
Class IIb
"1. Elective PCI might be considered in hospitals without on-site cardiac surgery, provided that appropriate planning for program development has been accomplished and rigorous clinical and angiographic criteria are used for proper patient selection.[ 106] [ 107] [ 108] (Level of Evidence: B ) "
Procedures The term balloon angioplasty is commonly used to describe percutaneous coronary intervention, which describes the inflation of a balloon within the coronary artery to crush the plaque into the walls of the artery. While balloon angioplasty is still done as a part of nearly all percutaneous coronary interventions, it is rarely the only procedure performed.
Other procedures that are done during a percutaneous coronary intervention include:
2011 ACCF/AHA/SCAI Guideline Recommendations: Procedural Considerations [ 1] ACCF/AHA Guidelines for Vascular Access[ 1] ACCF/AHA Guidelines for PCI in patients with Stable Ischemic Heart Disease (SIHD)[ 118] Patients With Asymptomatic Ischemia or CCS Class I or II Angina[ 118] Patients With CCS Class III Angina[ 118] PCI in patients with ST-Elevation Myocardial Infarction[ 1] Coronary Angiography Strategies in STEMI[ 1] Delayed or Elective PCI in Patients with STEMI[ 1]
Class III (No Benefit)
"1. PCI of a totally occluded infarct artery greater than 24 hours after STEMI should not be performed in asymptomatic patients with 1- or 2-vessel disease if patients are hemodynamically and electrically stable and do not have evidence of severe ischemia .[ 132] [ 133] [ 134] (Level of Evidence: B ) "
Patients With STEMI: General and Specific Considerations[ 118] PCI in Fibrinolytic-Ineligible Patients[ 118] Facilitated PCI[ 118] Rescue PCI (PCI After Failed Fibrinolysis)[ 118] PCI After Successful Fibrinolysis or for Patients Not Undergoing Primary Reperfusion[ 118] PCI in patients with Cardiogenic Shock [ 1]
PCI in patients with Prior Coronary Bypass Surgery [ 118]
Revascularization Before Non-cardiac Surgery [ 1]
Coronary Stents [ 1]
2011 ACCF/AHA/SCAI Guideline Recommendations: Adjunctive Diagnostic Devices [ 1] Fractional Flow Reserve [ 1]
Intravascular Ultrasound [ 1]
2011 ACCF/AHA/SCAI Guideline Recommendations: Adjunctive Therapeutic Devices [ 1] Coronary Atherectomy [ 1]
Thrombectomy [ 1]
Laser Angioplasty [ 1]
Cutting Balloon Angioplasty [ 1]
Embolic Protection Devices [ 1]
2011 ACCF/AHA/SCAI Guideline Recommendations: Percutaneous Hemodynamic Support Devices [ 1] Percutaneous Hemodynamic Support Devices
Class IIb
"1. Elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable in carefully selected high-risk patients. (Level of Evidence: C ) "
2011 ACCF/AHA/SCAI Guideline Recommendations: Antiplatelet Therapy [ 1] Oral Antiplatelet Therapy [ 1]
Intravenous Antiplatelet Therapy: ST-Elevation Myocardial Infarction (STEMI) [ 1]
Intravenous Antiplatelet Therapy: Unstable Angina / Non-ST Elevation Myocardial Infarction (UA/NSTEMI) [ 1]
Intravenous Antiplatelet Therapy: Sudden Ischemia Heart Disease (SIHD) [ 1]
2011 ACCF/AHA/SCAI Guideline Recommendations: Anticoagulant Therapy [ 1] Use of Parenteral Anticoagulants during PCI [ 1]
Unfractionated Heparin [ 1] Enoxaparin [ 1]
Bivalirudin and Argatoban [ 1]
Fondaparinux [ 1]
No-Reflow Pharmacological Therapies [ 1]
2011 ACCF/AHA/SCAI Guideline Recommendations: PCI in Specific Anatomic Situations [ 1] Chronic Total Occlusions [ 1]
Saphenous Vein Grafts [ 1]
Bifurcation Lesions [ 1]
Aorto-Ostial Stenoses [ 1]
Calcified Lesions [ 1]
2011 ACCF/AHA/SCAI Guideline Recommendations: PCI in Specific Patient Population [ 1] Chronic Kidney Disease 2011 ACCF/AHA/SCAI Guideline Recommendations: Peri-procedural Myocardial Infarction Assessment[ 1] Peri-procedural Myocardial Infarction Assessment 2011 ACCF/AHA/SCAI Guideline Recommendations: Vascular Closure Devices [ 1] Vascular Closure Devices
Class I
"1. Patients considered for vascular closure devices should undergo a femoral angiogram to ensure their anatomic suitability for deployment. (Level of Evidence: C ) "
2011 ACCF/AHA/SCAI Guideline Recommendations: Post-procedural Antiplatelet Therapy [ 1] Post-procedural Antiplatelet Therapy Proton Pump Inhibitors and Anti-platelet Therapy [ 1]
Clopidogrel Genetic Testing [ 1]
Platelet Function Testing [ 1]
2011 ACCF/AHA/SCAI Guideline Recommendations: Restenosis [ 1] Restenosis Exercise Testing [ 1]
Class III (No Benefit)
"1. Routine periodic stress testing of asymptomatic patients after PCI without specific clinical indications should not be performed.[ 340] (Level of Evidence: C ) "
Class IIa
"1. In patients entering a formal cardiac rehabilitation program after PCI, treadmill exercise testing is reasonable. (Level of Evidence: C ) "
Cardiac Rehabilitation [ 1]
2011 ACCF/AHA/SCAI Guideline Recommendations: Quality and Performance Considerations [ 1] Quality and Performance [ 1]
Certification and Maintenance of Certification [ 1]
Class IIa
"1. It is reasonable for all physicians who perform PCI to participate in the American Board of Internal Medicine interventional cardiology board certification and maintenance of certification program. (Level of Evidence: C ) "
Operator and Institutional Competency and Volume [ 1]
Class III (No Benefit)
"1. It is not recommended that elective/urgent PCI be performed by low-volume operators (75 procedures per year) at low-volume centers (200 to 400 procedures per year) with or without on-site cardiac surgery . An institution with a volume of fewer than 200 procedures per year, unless in a region that is underserved because of geography, should carefully consider whether it should continue to offer this service.[ 350] (Level of Evidence: C ) "
Class IIa
"1. It is reasonable that operators with acceptable volume (75 PCI procedures per year) perform elective/urgent PCI at low-volume centers (200 to 400 PCI procedures per year) with on-sitecardiac surgery .[ 350] (Level of Evidence: C ) "
"2. It is reasonable that low-volume operators (75 PCI procedures per year) perform elective/urgent PCI at high-volume centers (more than 400 PCI procedures per year) with on-site cardiac surgery. Ideally, operators with an annual procedure volume of fewer than 75 procedures per year should only work at institutions with an activity level of more than 600 procedures per year. Operators who perform fewer than 75 procedures per year should develop a defined mentoring relationship with a highly experienced operator who has an annual procedural volume of at least 150 procedures. (Level of Evidence: C ) "
Guideline Resources References
↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27 1.28 1.29 1.30 1.31 1.32 1.33 1.34 1.35 1.36 1.37 1.38 1.39 1.40 1.41 1.42 1.43 1.44 1.45 1.46 1.47 1.48 1.49 1.50 1.51 1.52 1.53 1.54 1.55 1.56 1.57 1.58 1.59 1.60 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF) . Journal of the American College of Cardiology 58 (24): 2550–83. doi :10.1016/j.jacc.2011.08.006 . PMID 22070837 . Retrieved 2011-12-08 . ↑ Feit F, Brooks MM, Sopko G, Keller NM, Rosen A, Krone R et al. (2000)Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators. Circulation 101 (24):2795-802. PMID: [1]
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↑ 23.0 23.1 Biondi-Zoccai GG, Lotrionte M, Moretti C, Meliga E, Agostoni P, Valgimigli M et al. (2008) A collaborative systematic review and meta-analysis on 1278 patients undergoing percutaneous drug-eluting stenting for unprotected left main coronary artery disease. Am Heart J 155 (2):274-83.DOI:10.1016/j.ahj.2007.10.009 PMID:18215597
↑ 24.0 24.1 Boudriot E, Thiele H, Walther T, Liebetrau C, Boeckstegers P, Pohl T et al. (2011)Randomized comparison of percutaneous coronary intervention with sirolimus-eluting stents versus coronary artery bypass grafting in unprotected left main stem stenosis. J Am Coll Cardiol 57 (5):538-45.DOI:10.1016/j.jacc.2010.09.038 PMID:21272743
↑ 25.0 25.1 25.2 Brener SJ, Galla JM, Bryant R, Sabik JF, Ellis SG (2008) Comparison of percutaneous versus surgical revascularization of severe unprotected left main coronary stenosis in matched patients. Am J Cardiol 101 (2):169-72. [8] PMID: 18178401
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↑ 28.0 28.1 28.2 Lee MS, Kapoor N, Jamal F, Czer L, Aragon J, Forrester J et al. (2006)Comparison of coronary artery bypass surgery with percutaneous coronary intervention with drug-eluting stents for unprotected left main coronary artery disease. J Am Coll Cardiol 47 (4):864-70. [10] PMID: 16487857
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↑ 30.0 30.1 Naik H, White AJ, Chakravarty T, Forrester J, Fontana G, Kar S et al. (2009)A meta-analysis of 3,773 patients treated with percutaneous coronary intervention or surgery for unprotected left main coronary artery stenosis. JACC Cardiovasc Interv 2 (8):739-47. [11] PMID: 19695542
↑ 31.0 31.1 Palmerini T, Marzocchi A, Marrozzini C, Ortolani P, Saia F, Savini C et al. (2006) Comparison between coronary angioplasty and coronary artery bypass surgery for the treatment of unprotected left main coronary artery stenosis (the Bologna Registry). Am J Cardiol 98 (1):54-9.DOI:10.1016/j.amjcard.2006.01.070 PMID:16784920
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↑ 34.0 34.1 34.2 Sanmartín M, Baz JA, Claro R, Asorey V, Durán D, Pradas G et al. (2007) Comparison of drug-eluting stents versus surgery for unprotected left main coronary artery disease. Am J Cardiol 100 (6):970-3.DOI:10.1016/j.amjcard.2007.04.037 PMID:17826380
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