Basics of pci

Basics of Percutaneous Coronary Intervention

Basics of Percutaneous Coronary InterventionDr Waseem A Siddiqui, MD, MBBS

EPIDEMIOLOGY CORONARY HEART DISEASE (CHD)

Major causes of morbidity and mortality all over the world

In 2016, American Heart Association (AHA) reported that 15.5 million persons > 20 years of age in USA have CHD, & prevalence increases with age

Every 42 seconds, an American suffers from MI1

CHD mortality declined over the last decades in western countries, it is expected to continue increasing in developing countries2

Age-standardized CVD death rate is 272/ 100000 population inIndia, whichis higher than global average of 235 per 100000 population.2

Current estimates from epidemiologic studies show prevalence of CHD 7-13% in urbanand 2-7% in rural area.3

1. https://www.ncbi.nlm.nih.gov/pubmed/229298182. https://www.ncbi.nlm.nih.gov/pubmed/?term=cardiovascular+disease+in+India.+Current+Epidemiology+and+Future+directions3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860846

2

TREATMENT MODALITIES http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/coronary-artery-disease

PERCUTANEOUS CORONARY INTERVENTIONSPercutaneous coronary interventions (PCI) include percutaneous transluminal coronary angioplasty (PTCA) with or without stent insertion First performed in human by Andreas Gruentzig in 1971

Most commonly performed interventional procedure

PTCA and stent placement within 90 min of onset of pain is the optimal treatment of transmural ST-segmentelevation myocardial infarction (STEMI).

Elective PCI may be appropriate for post-MI patients who have recurrent or inducible angina before hospital discharge and for patients who have angina and remain symptomatic despite medical treatment.

Michael J. Shea. Percutaneous Coronary Interventions. MSDManual. Feb, 2016

INDICATIONS Acute ST-elevation myocardial infarction (STEMI)NonST-elevation acute coronary syndrome (NSTE-ACS)Unstable anginaStable anginaAnginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope)High risk stress test findings

CONTRAINDICATIONS Coagulopathy Decompensated congestive heart failureUncontrolled HypertensionPregnancyInability for patient cooperationActive infectionRenal FailureContrast medium allergy

George A Stouffer, at al. Percutaneous Coronary Intervention (PCI). Drug and disease, Oct. 16.

TYPES OF PCI IN ACS WITH STEMIPrimary PCI: Procedure is performed within 12 hours after the onset of symptoms.Rescue PCI: Rescue PCI is recommended if thrombolysis failed within 45-60 min after starting the administrationPost thrombolysis PCI: Thrombolysis-facilitated primary PCI Ischaemia guided PCI: Ischaemia-driven PCI after thrombolysis

Ali Ghanie. Indication for Percutaneous Coronary Angioplasty. Acta Med Indones-Indones J Intern Med. 2009; 41: 159-65

EQUIPMENTS

Balloon catheters for PCI have the following features:A steerable guide wire precedes balloon into artery & permits navigation through coronary treeInflation of balloon compresses & axially redistributes atheromatous plaque & stretches vessel wallBalloon catheter also serves as adjunctive device for many other interventional therapies

Intracoronary stents have the following features:Stents differ with respect to composition, design, delivery system & drug deliveredDrug-eluting stents (DESs) have demonstrated significant reductions in re-stenosis & target-lesion revascularization rates, with further reduction with second-generation DESsIn the United States, commercially available DESs are second-generation models that elute everolimus & zotarolimusBoth stents with bio-absorbable polymer & fully bioresorbable scaffoldsStents are conventionally placed after balloon predilation, but in selected coronary lesions, direct stenting may lead to better outcomes

George A Stouffer, at al. Percutaneous Coronary Intervention (PCI). Drug and disease, Oct. 16.

PROCEDURE

PCI is done via percutaneous femoral, radial, or brachial artery puncture. Radial approach is technically demanding compared to the femoral approach but may reduce patient discomfort, improve time to ambulation, and reduce the incidence of some complications (eg, bleeding, pseudoaneurysm formation).A guiding catheter is inserted into a large peripheral artery and threaded to appropriate coronary ostium. A balloon-tipped catheter, guided by fluoroscopy or intravascular ultrasonography, is aligned within the stenosis, then inflated to disrupt the atherosclerotic plaque and dilate the artery.Angiography is repeated after the procedure to document any changes. The procedure is commonly done in 2 or 3 vessels as needed.


ANTICOAGULATION & ANCILLARY THERAPY

Antithrombotic therapy: Aspirin (162-325 mg) F/B Unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or bivalirudin used at the time of balloon angioplasty or PCI.

Antiplatelet therapyThienopyridines (clopidogrel,prasugrel,ticagrelor) and glycoprotein IIb/IIIa inhibitors (abciximab,eptifibatide,tirofiban) are the standard of care for patients with unstable non-ST-segment elevation myocardial infarction for at least 9 to 12 months after PCI.

Glycoprotein inhibitor therapyAbciximab, tirofiban, and eptifibatide reduce ischemic complications in patients undergoing balloon angioplasty and coronary stenting. Calcium channel blockers and nitrates may also reduce risk of coronary spasm.


STENT TYPEShttps://www.orbusneich.com/en/patient/types-coronary-stents-0 Stainless steel, without special coating As artery heals, tissue grows around stent holding it in place Overgrowth of scar tissue- risk of re-blockage Coated with medications that help to prevent the growth of scar tissue in the artery lining chances of blood clots stent thrombosis

COMPICATIONS

MAJORAllergic & Adverse reaction (30%)Acute MI requiring emergency CABG (5-30%)Distal embolization (

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Basics of pci