Coronary artery disease (CAD) is one of the leading causes of death. Percutaneous coronary intervention (PCI) is a non-surgical, invasive procedure with a goal to relieve the narrowing or occlusion of the coronary artery and improve blood supply to the ischemic tissue. This is usually achieved by different methods, most common being ballooning of the narrow segment or deployment of a stent to keep the artery open.
The access to the bloodstream is achieved through either the femoral or radial artery. Real-time X-ray fluoroscopy is used to visualize the location of the catheter and tissues. The catheter is advanced to ascending aorta. Coronary arteries are engaged using different catheters for the right and left coronary artery. IV contrast is introduced in the coronary artery to delineate the anatomy. Pictures of coronary arteries are taken from different angles to help access the three-dimensional nature of the narrowing.
The following are the clinical indications that could require a percutaneous coronary intervention.
Percutaneous coronary intervention is performed during an angiogram in the angiography suite. Other than standard equipment following supplies may be used on the case to case bases.
Door to balloon time:
The door-to-balloon time (D2B time) is used as a measure to improve the timing of PCI in patients with STEMI. It defines a time taken between a patient's arrival to balloon inflation during the angiogram. Studies have shown improved in-hospital mortality, which showed a shorter door to balloon times. ST-elevation myocardial infarction (STEMI) patients in the NRMI-3 and 4 registries (1999 to 2002) who were treated with percutaneous coronary intervention (PCI) within six hours of presentation, longer D2B times were significantly associated with increased in-hospital mortality (3.0, 4.2, 5.7, and 7.4 percent for D2B time of less than or equal to 90 minutes, 91 to 120 minutes, 121 to 150 minutes, and greater than 150 minutes, respectively).
Access type: Femoral vs. Radial access:
Coronary arteries can be accessed for angiogram through a radial or femoral approach. In general, radial artery approach is preferred to reduce the risk of access site bleeding because the radial artery can be easily compressed against the radial bone, as compared to the femoral artery. However, access to the radial artery requires experience and expertise because of its small size.
Before access through the radial artery, palmar arch circulation should be assessed to avoid ischemia of the hand from complications during the procedure.
A meta-analysis was done in 2016, based on 24 trials for acute coronary syndrome patients: RIVAL, MATRIX, RIFLE-STEACS, and STEMI RADIAL: Showed a reduction in following endpoints in patients who had the procedure done through the radial approach.
Antiplatelets therapy and its indication in percutaneous coronary intervention:
After preparing the access site for approach, usually the groin for the femoral artery approach, an introducer needle is inserted in the artery. A guidewire is passed, and the needle is withdrawn. Once the access is gained, a "sheath introducer" is inserted over the guidewire, which helps to keep the artery open. A sheath is then inserted through the sheath introducer. The sheaths are flexible hollow tubes used to introduce different catheters. Different types of sheaths are used to access different locations like right and left coronary arteries and left ventricle. With x-ray fluoroscopy, contrast material is introduced in the coronary artery to delineate its anatomy. Stenosis or occlusion of the coronary artery is then visualized, and severity is estimated through pictures at different angles. If stenosis or occlusion is located, the cardiologist then introduces a guidewire through the catheter and positions the tip of the wire distal to the stenosis in the artery. This guidewire is then used to introduce the balloon or stent catheter over it for angioplasty or stent placement, respectively. For stent placement, the catheter has the stent positioned over the balloon, and once in the right location, the balloon can be expanded, which stretches the stent open over the balloon. The catheter can then be withdrawn. Images are taken to confirm the proper location of the stent and resolution of stenosis.
Percutaneous coronary intervention
Intravascular ultrasound (IVUS) enables visualization up coronary artery wall using a mini ager ultrasound transducer at the end of the flexible catheter, it helps in delineating the plaque morphology and distribution and helps in rationalizing the PCI. The benefit of IVUS is in the utility of intra-lumen measurements, which is not possible with coronary angiography as the view taken is usually two-dimensional, and does not represent the true lumen diameter accurately because of limitations of contrast enhancement, angle of view, especially in asymmetric narrowing and complex luminal shapes.
PCI in Non-Coronary Vessels
Coronary artery or aortic injury:
The complication rate is higher in patients with:
Percutaneous coronary intervention is being used extensively over the last many years. 80% of PCI is being done with stents. Over the past 20 years, short term mortality, MI, and target vessel revascularization has shown a significant reduction in patients with PCI.
Comparing the outcomes in different trials for PCI vs. CABG and medical therapy, the following are the preferred treatments for different patient categories. SYNTAX score is a tool used to estimate the complexity of coronary lesions and helps determine the decision-making process between PCI or CABG.
PCI vs. CABG
PCI vs. Medical Therapy
A heart team approach is recommended in patients with multivessel disease or severe left main disease and a high Syntax score. The team consists of interventional cardiology and cardiac surgery.
Same-day discharge after percutaneous coronary intervention showed comparable results with overnight admission in two metanalyses.
Early discharge in patients with STEMI after PCI:
In low-risk patients with ST-elevation MI, who undergo percutaneous coronary intervention, early discharge (defined as discharge at 72 hours), had shown improved outcomes.
In one study which used Zwolle risk index, and classified two-third of its patients at low risk of 3 or less [classified as low risk]. Mortality for these patients was 0.1% at 2 days and 0.2% from 2 to 10 days post-MI. It was suggested that such patients could be discharged safely after 48 hours of PCI.
PAMI-2 Trial had low-risk patients after PCI assigned to accelerated care or traditional care. Patients with accelerated care had discharge on day 3. They showed a significant reduction in cost. There was no difference in mortality, unstable angina, reinfarction, stroke, and heart failure between the 2 groups at 6 months.
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