Preparation of the patient for PCI

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Percutaneous coronary intervention Microchapters


Patient Information


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
Distal Embolization
Coronary Vasospasm
Abrupt Closure
Access Site Complications
Peri-procedure Bleeding
Renal Failure
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
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. [7] Associate Editor(s)-in-Chief: Anahita Deylamsalehi, M.D.[8]


There are several steps involved in preparing patients 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, use of statins, bleeding risk in patients, and the presence of on-site surgical backup services.

Preparation of the Patient for PCI


  1. Aspirin
  2. Clopidogrel

2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization. GENERAL PROCEDURAL ISSUES FOR PCI (Please do not edit)

Radial and Femoral Approaches for PCI

Class I
"1. In patients with ACS undergoing PCI, a radial approach is indicated in preference to a femoral approach to reduce the risk of death, vascular complications, or bleeding. (Level of Evidence: A)"
"2. In patients with SIHD undergoing PCI, the radial approach is recommended to reduce access site bleeding and vascular complications(Level of Evidence: A)"

[1] Choice of Stent Type

Class I
"1. In patients undergoing PCI, DES should be used in preference to BMS to prevent restenosis, MI, or acute stent thrombosis (Level of Evidence: A)"


Use of Intravascular Imaging

Class IIa
" 1. In patients undergoing coronary stent implantation, IVUS can be useful for procedural guidance, particularly in cases of left main or complex coronary artery stenting, to reduce ischemic events. (Level of Evidence B-R)".
'' 2. In patients undergoing coronary stent implantation, OCT is a reasonable alternative to IVUS for procedural guidance, except in the ostial left main disease.(Level of Evidence B-R)''
''3. In patients with stent failure, IVUS or OCT is reasonable to determine the mechanism of stent failure.(Level of Evidence C-LD)''



Class III (No Benefit)
"1. In patients with STEMI, routine aspiration thrombectomy before primary PCI is not useful. (Level of Evidence:A) "


Treatment of Calcified Lesions

Class IIa
" 1. In patients with fibrotic or heavily calcified lesions, plaque modification with rotational atherectomy can be useful to improve procedural success (Level of Evidence B-R)".


Class IIb
" 2. In patients with fibrotic or heavily calcified lesions, plaque modification with orbital ather-ectomy, balloon atherotomy, laser angioplasty, or intracoronary lithotripsy may be considered to improve procedural success. (Level of Evidence B-NR)".


Treatment of Saphenous Vein Graft (SVG) Disease (Previous CABG)

Class IIa
" 1. In select patients with previous CABG undergoing PCI of an SVG, the use of an embolic protection device, when technically feasible, is reasonable to decrease the risk of distal embolization (Level of Evidence B-R)".
'' 2. In patients with previous CABG, if PCI of a diseased native coronary artery is feasible, then it is reasonable to choose PCI of the native coronary artery over PCI of the severely diseased SVG(Level of Evidence B-NR)''


Class III (No Benefit)
"1. In patients with a chronic occlusion of an SVG, percutaneous revascularization of the SVG should not be performed (Level of Evidence:C-LD) "


Treatment of CTO

Class IIb
" 1. In patients with suitable anatomy who have refractory angina on medical therapy, after treatment of non-CTO lesions, the benefit of PCI of a CTO to improve symptoms is uncertain. (Level of Evidence B-R)".


Treatment of Patients With Stent RestenosisRecommendations

Class I
"1. In patients who develop clinical in-stent restenosis (ISR) for whom repeat PCI is planned, a DES should be used to improve outcomes if anatomic factors are appropriate and the patient is able to comply with DAPT (Level of Evidence: A)"


Class IIa
" 2. In patients with symptomatic recurrent diffuse ISR with an indication for revascularization, CABG can be useful over repeat PCI to reduce recurrent events. (Level of Evidence C-EO)".


Class IIb
" 1. In patients who develop recurrent ISR, brachytherapy may be considered to improve symptoms. (Level of Evidence B-NR)".


Hemodynamic Support for Complex PCI

Class IIb
" 1. In selected high-risk patients, elective insertion of an appropriate hemodynamic support device as an adjunct to PCI may be reasonable to prevent hemodynamic compromise during PCI(Level of Evidence B-R)".


2011 and 2005 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[2][3]

Heart Team Approach to Revascularization Decisions (DO NOT EDIT)[2]

Class I

"1. A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD. [4][5][6] (Level of Evidence: C)"

Class IIa

"1. Calculation of the Society of Thoracic Surgeons and SYNTAX (Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery) scores is reasonable in patients with unprotected left main and complex CAD. [6][7][8][9][10][11][12][13] (Level of Evidence: B)"

Contrast-Induced Acute Kidney Injury (DO NOT EDIT)[2]

Class I

"1. Patients should be assessed for risk of contrast-induced acute kidney injury before PCI.[14][15] (Level of Evidence: C)"

"2. Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration.[16][17][18][19] (Level of Evidence: B)"

"3. In patients with chronic kidney disease (CKD) (creatinine clearance ≤60 mL/min), the volume of contrast media should be minimized.[20][21][22] (Level of Evidence: B)"

Class III (No Benefit)
"1. Administration of N-acetyl-L-cysteine is not useful for the prevention of contrast-induced acute kidney injury.[23][24] [25][26][27] (Level of Evidence: A)"

Anaphylactoid Reactions (DO NOT EDIT)[2]

Class I

"1. Patients with prior evidence of an anaphylactoid reaction to contrast media should receive appropriate steroid and antihistamine prophylaxis before repeat contrast administration. [28][29][30][31](Level of Evidence: B)"

Class III (No Benefit)
"1. In patients with a prior history of allergic reactions to shellfish or seafood, anaphylactoid prophylaxis for contrast reaction is not beneficial. [32][33][34](Level of Evidence: C)"

Statin Treatment (DO NOT EDIT)[2]

Class IIa

"1. Administration of a high-dose statin is reasonable before PCI to reduce the risk of peri-procedural myocardial infarction. (Level of Evidence: A forstatin-naïve patients) [35][36][37][38][39][40][41];(Level of Evidence: B for those on chronic statin therapy) [42]"

Bleeding Risk (DO NOT EDIT)[2]

Class I

"1. All patients should be evaluated for risk of bleeding before PCI. (Level of Evidence: C)"

PCI in Hospitals Without On-Site Surgical Backup (DO NOT EDIT)[2]

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.[43][44] (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.[44][45][46] (Level of Evidence: B)"

Role of Onsite Cardiac Surgical Back-Up (DO NOT EDIT)[3]

Class I
"1. Elective PCI should be performed by operators with acceptable annual volume (at least 75 procedures per year) at high-volume centers (more than 400 procedures annually) that provide immediately available onsite emergency cardiac surgical services. (Level of Evidence: B)"
"2. Primary PCI for patients with STEMI should be performed in facilities with onsite cardiac surgery.(Level of Evidence: B)"
Class III
"1. Elective PCI should not be performed at institutions that do not provide onsite cardiac surgery. (Level of Evidence: C)"

ACA 2021 Revascularization Guideline


Class III (No Benefit)[47]
Routine aspiration thrombectomy is not useful before primary PCI in patients with ST elevation myocardial infarction.


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