Percutaneous coronary intervention overview

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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.




References

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