Transcript Percutaneous Coronary Intervention

Percutaneous Coronary
Intervention
Sripal Bangalore, M.D., M.H.A.
and
Deepak L. Bhatt, M.D., M.P.H., F.A.H.A
Copyright © 2011 American Heart Association.
Overview
Percutaneous Coronary Intervention
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Indications
Contraindications / Caution
Equipment
Technique
Precautions
Guide catheter selection
Guidewire selection
Guidewire: Tips & tricks
Complications
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Dissection
Perforation
Copyright © 2011 American Heart Association.
Indications
Asymptomatic Ischemia or CCS Class I or II Angina (Class I and III only)
I IIa IIb III
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No Class I indication
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PCI is not recommended in patients with asymptomatic ischemia or
CCS class I or II angina who have 1 or more of the following:
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Only a small area of viable myocardium at risk
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No objective evidence of ischemia
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Lesions that have a low likelihood of successful dilatation
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Mild symptoms that are unlikely to be due to myocardial
ischemia
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Factors associated with increased risk of morbidity or mortality
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Insignificant disease (less than 50% coronary stenosis)
Source: Smith SC Jr et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation. 2006;113:e166–e286
Indications
CCS Class III Angina (Class I and III only)
I IIa IIb III
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No Class I indication
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PCI is not recommended for patients with CCS class III angina with
single-vessel or multivessel CAD, no evidence of myocardial injury or
ischemia on objective testing, and no trial of medical therapy, or who
have 1 of the following:
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Only a small area of myocardium at risk
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All lesions or the culprit lesion to be dilated with morphology that
conveys a low likelihood of success
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A high risk of procedure-related morbidity or mortality
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Insignificant disease (less than 50% coronary stenosis
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Significant left main CAD and candidacy for CABG
Source: Smith SC Jr et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation. 2006;113:e166–e286
Indications
Patients With UA/NSTEMI (Class I and III only)
I IIa IIb III
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An early invasive PCI strategy is indicated for patients with UA/NSTEMI who have no
serious comorbidity and coronary lesions amenable to PCI. Patients must have any of the
following high-risk features:
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Recurrent ischemia despite intensive anti-ischemic therapy
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Elevated troponin level
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New ST-segment depression
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Heart failure symptoms or new or worsening MR
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Depressed LV systolic function
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Hemodynamic instability
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Sustained ventricular tachycardia
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PCI within 6 months
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Prior CABG
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In the absence of high-risk features associated with UA/NSTEMI, PCI is not
recommended for patients with UA/NSTEMI who have single-vessel or multivessel CAD
and no trial of medical therapy, or who have 1 or more of the following:
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Only a small area of myocardium at risk

All lesions or the culprit lesion to be dilated with morphology that conveys a low
likelihood of success

A high risk of procedure-related morbidity or mortality

Insignificant disease (less than 50% coronary stenosis)

Significant left main CAD and candidacy for CABG
Source: Smith SC Jr et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation. 2006;113:e166–e286
Indications
Patients With STEMI (Class I and III only)
I IIa IIb III
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If immediately available, primary PCI should be performed in patients with STEMI
(including true posterior MI) or MI with new or presumably new left bundle branch block
who can undergo PCI of the infarct artery within 12 hours of symptom onset, if performed
in a timely fashion (balloon inflation goal within 90 minutes of presentation) by persons
skilled in the procedure (individuals who perform more than 75 PCI procedures per year,
ideally at least 11 PCIs per year for STEMI). The procedure should be supported by
experienced personnel in an appropriate laboratory environment (one that performs more
than 200 PCI procedures per year, of which at least 36 are primary PCI for STEMI, and
that has cardiac surgery capability)
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Primary PCI should be performed as quickly as possible, with a goal of a medical contactto-balloon or door-to-balloon time within 90 minutes.
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Primary PCI should be performed for patients less than 75 years old with ST elevation or
presumably new left bundle-branch block who develop shock within 36 hours of MI and
are suitable for revascularization that can be performed within 18 hour of shock, unless
further support is futile because of the patient’s wishes or contraindications/unsuitability
for further invasive care
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Primary PCI should be performed in patients with severe congestive heart failure and/or
pulmonary edema (Killip class 3) and onset of symptoms within 12 hours. The medical
contact-to-balloon or door-to balloon time should be as short as possible (i.e., goal within
90 minutes)
Source: Smith SC Jr et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation. 2006;113:e166–e286
Indications
Patients With STEMI (Class I and III only)
I IIa IIb III

Elective PCI should not be performed in a noninfarct-related artery
at the time of primary PCI of the infarct related artery in patients
without hemodynamic compromise
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Primary PCI should not be performed in asymptomatic patients
more than 12 hours after onset of STEMI who are hemodynamically
and electrically stable
Source: Smith SC Jr et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation. 2006;113:e166–e286
Indications
PCI for Cardiogenic Shock (Class I and III only)
I IIa IIb III
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Primary PCI is recommended for patients less than 75 years old
with ST elevation or left bundle-branch block who develop shock
within 36 hours of MI and are suitable for revascularization that
can be performed within 18 hours of shock, unless further support
is futile because of the patient’s wishes or contraindications/
unsuitability for further invasive care
Source: Scanlon PJ et al. ACC/AHA Guidelines for Coronary Angiography: Executive Summary and Recommendations. A Report of the American College of Cardiology/American Heart Association
Task Force on Practice Guidelines (Committee on Coronary Angiography). Circulation 1999;99;2345-2357
Indications
Patients With Prior Coronary Bypass Surgery (Class I and III only)
I IIa IIb III
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When technically feasible, PCI should be performed in patients with early
ischemia (usually within 30 days) after CABG
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It is recommended that distal embolic protection devices be used when
technically feasible in patients undergoing PCI to saphenous vein grafts
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PCI is not recommended in patients with prior CABG for chronic total vein
graft occlusions
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PCI is not recommended in patients who have multiple target lesions with
prior CABG and who have multivessel disease, failure of multiple SVGs, and
impaired LV function unless repeat CABG poses excessive risk due to severe
comorbid conditions
Source: Smith SC Jr et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines. Circulation. 2006;113:e166–e286
Contraindications
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There are no absolute contraindications to PCI.
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Relative contraindications include:
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Coagulopathy (Radial approach can be attempted based on
urgency)
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Decompensated congestive heart failure
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Uncontrolled Hypertension
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Pregnancy
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Inability for patient cooperation
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Active infection
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Renal Failure
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Contrast medium allergy
Copyright © 2011 American Heart Association.
Equipment & Technique
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Conscious sedation using a narcotic and a benzodiazepine
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Vascular access: femoral (described in the section on vascular access and
closure devices), radial, or brachial
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Antiplatelet therapy with aspirin and a thienopyridine (clopidogrel or
prasugrel)
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Antithrombotic therapy with either unfractionated heparin, low
molecular weight heparin, or bivalirudin
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Glycoprotein receptor IIB/IIIA inhibitors can be used based on the
procedure
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Flush the selected guiding catheter (connected to a Y-port) with saline to
ensure an air free system
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Once arterial access is obtained (as described in the section on vascular
access and closure devices) a guiding catheter of appropriate size and
configuration is advanced over a 0.035 or 0.038 inch guidewire
Copyright © 2011 American Heart Association.
Technique
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Once in the ascending aorta, the guidewire is removed, the catheter
allowed to bleed back to remove any thrombus or atherosclerotic debris
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The catheter is then connected to a manifold assembly connected to a
pressure transducer for continuous central pressure monitoring
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The guiding catheter is flushed to ensure an air free system
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The guiding catheter should then be filled with 3-4 cc of contrast and
advanced to engage the coronary ostium, in the LAO projection
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After ensuring that there is no ventricularization or damping of the
pressure, 2 to 3 cc of contrast should be injected to confirm the position of
the catheter in the coronary ostium
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After adequate antithrombotic agents have been given, a 0.014 inch
guidewire is advanced through the guide catheter into the coronary artery
and across the lesion
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At this stage, in the setting of thrombotic STEMI lesions, a manual
aspiration catheter can be used to aspirate thrombus
Copyright © 2011 American Heart Association.
Technique
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For SVG interventions, an embolic protection device should be deployed
prior to any angioplasty or stenting if feasible (as described in the
section on EPDs)
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An appropriate size compliant balloon may now be advanced over this
guidewire to the region of the stenosis and the balloon inflated with
saline/contrast to pre-dilate the lesion
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The balloon is then removed
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Pre-dilatation should be avoided in SVG grafts (if possible) to prevent
distal embolization
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Once adequate pre-dilatation is performed, a stent of suitable type, size,
and length is taken and is flushed to ensure an air-free system
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This is advanced over the guidewire, across the lesion and deployed by
inflating the balloon mounted stent to appropriate pressures
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The stent balloon is now removed and coronary angiography performed
to ensure no complications and to assess for adequate stent expansion
Copyright © 2011 American Heart Association.
Technique
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Some laboratories believe in routine post-dilatation of all stents (except
SVG interventions) to ensure adequate strut expansion
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If desired, this is accomplished by using a non-compliant balloon of
appropriate size and length
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The balloon is removed and coronary angiography performed in two
orthogonal views assessing the following:
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Stent and the proximal and distal edge to ensure no dissections or
perforation
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The distal wire site to ensure no perforation
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The ostium to ensure no dissection caused by the guiding catheter
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The guidewire is then removed and angiography is performed to confirm
adequate stent deployment and no complications as described above
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The guiding catheter should then be removed and intravenous
antithrombotic therapy stopped unless further continuation is required
due to heavy thrombus burden
Copyright © 2011 American Heart Association.

Guide Catheter Selection
Depending on the support provided by the guide catheter, they can be
divided into the following 3 types:
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Standard guide catheters which do not provide any additional
support. Examples: JL4, JR4, etc.
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Support guide catheters - these rest in the sinus of valsalva and
provide more support than the standard guide catheters. Examples:
AL, AR, etc.
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Extra support guide catheters - these provide extra support from the
back wall of the aorta and are especially useful in situations needing
extra support such as tortuous or calcified lesions, chronic total
occlusions, etc. Examples: EBU, XB, etc.
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Coronary stenting can be performed using 4 to 6Fr guide catheters
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Larger guide catheters (7-8Fr) are needed for more complex proceduresbifurcation stenting, rotational atherectomy, to provide extra support for
chronic total occlusions or tortuous and calcified lesions
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Coronary Guidewire Selection
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Coronary guidewires are usually 0.010-0.018in diameter with the most
commonly used being 0.014in made of stainless steel or nitinol
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Length: standard length -175 to 190 cm; Exchange length- 270-400 cm
Guidewires are classified:
 Based on coating (increasing order of lubricity and decreasing order
of tactile feedback)
 No coating
 Hydrophobic
 Hydrophilic - becomes gel when wet and reduces friction
 Polymer cover with hydrophilic coating
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Based on support
 Soft
 Moderate support
 Extra support - For chronic total occlusions
 Super extra support - For chronic total occlusions
Copyright © 2011 American Heart Association.
Coronary Guidewire: Tips & Tricks
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Always start with the least traumatic wire (‘work horse’ wire)
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Always advance the wire under fluoroscopic guidance
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Never allow the guidewire tip to buckle (more prone to dissection)
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Always ensure that the wire tip is free
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If on wire advancement, frequent PVC’s are noted, wire tip might have
perforated and may be irritating the myocardium. Withdraw the wire.
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If wire gets trapped and difficult to retrieve (especially in calcified
arteries) even with gentle traction, use a low profile balloon or small
caliber catheter and advance until hinge point and withdraw both as a unit
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For stenting over a bifurcation with a wire protecting the branch vessel,
always deploy the stent at low pressures, withdraw the branch wire, recross through the stent strut and post-dilate to high pressures.
If wire tip breaks off and embolizes:
 Attempt to retrieve it using a snare
 If attempts fail, tip may be plastered against the wall using a stent
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Copyright © 2011 American Heart Association.
Complications
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Apart from the complications listed under diagnostic coronary
angiography, those related to PCI include
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Abrupt closure and dissections
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Perforation
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Intramural hematoma
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Side branch occlusion
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Distal embolization
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Stroke
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Non-fatal MI
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Death
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Emergent CABG
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Others: ventricular arrhythmia, acute renal failure, radiation injury
Copyright © 2011 American Heart Association.
Complications: Dissections
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Usually due to balloon dilatation injury, during guidewire passage, or
trauma due to the guiding catheter
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Types:
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Type A — Luminal haziness
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Type B — Linear dissection
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Type C — Extraluminal contrast staining
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Type D — Spiral dissection
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Type E — Dissection with reduced flow
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Type F — Dissection with total occlusion
Treatment depends on the type of dissection and the TIMI flow of the
involved vessel. Though stenting is routinely used to treat dissections,
some dissections (Type A, B) can be left alone
Copyright © 2011 American Heart Association.
Complications: Perforation
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Usually due to guidewire exit, over-aggressive balloon dilation or stent
deployment, and rarely due to cutting balloon angioplasty or during
rotational atherectomy
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Types:
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Class I - intramural crater without extravasation
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Class II - pericardial or myocardial blushing (staining)
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Class III - perforation ≥1 mm in diameter with contrast streaming or
cavity spilling
Treatment depends on the type of perforation. For severe perforations the
following steps should be considered
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Stop anticoagulation and consider reversal
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Inflate balloon or a perfusion balloon to tamponade the site of
perforation
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Contra-lateral arterial access with an 8F sheath
Copyright © 2011 American Heart Association.
Complications: Perforation
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Severe perforation treatment (continued):
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If patient is hemodynamically unstable, perform pericardiocentesis
immediately
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Drain blood and autotransfuse into a central vein
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Deflate the coronary balloon periodically to see if the extravasation
stops. If not, reinflate the balloon to low pressures

Using contralateral access and an 8F guiding catheter, recross the site
of perforation using a second wire (partially deflating the balloon
when you are ready to cross the site)
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Load a suitable size PTFE coated stent onto the guidewire, deflate the
first balloon, and advance the stent to the site of perforation and
deploy the stent. This should seal the perforation site
Copyright © 2011 American Heart Association.