Percutaneous coronary intervention/Percutaneous trans luminal angioplasty

Question 1

Why is percutaneous Coronary intervention (PCI)

Answer 1

• a non-surgical procedure used to treat narrowing (stenosis) of the coronary arteries of the heart found in coronary artery disease -> CAD, congestive HF, acute MI

After accessing the blood stream through the femoral or radial artery, the procedure uses coronary catheterization to visualise the blood vessels on X-ray imaging.
After this, an interventional cardiologist can perform a coronary angioplasty, using a balloon catheter in which a deflated balloon is advanced into the obstructed artery and inflated to relieve the narrowing; certain devices such as stents can be deployed to keep the blood vessel open. Various other procedures can also be performed.

Question 2

which diseases to use Urgent Invasive strategy ?

Answer 2

Urgent invasive strategy (ASPA), done with GPIIb/IIIa (anticoagulant) for:

• refractory angina: which are chronic/resisting angina
• recurrent angina: angina showing therapy resistance, ST depression and deep T waves
• HF
• shock
• arrhythmia

Question 3

Which diseases to use early invasive ?

Answer 3

Early invasive, means in less than 72hrs

• presence of troponin biomarkers
• dynamic ST-T changes
• DM
• Renal failure
• EF < 40%
• angina in a patient that had past MI
• previous PCI
• high GRACE risk

Question 4

Use of PCI for a STEMI

Answer 4

• primary PCI in less than 72h after STEMI

- if not possible -> thrombolysis (later PCI), best within the first 3 hours

Question 5

Percutaneous transluminal angioplasty: technique

Answer 5

• Perform a percutaneous puncture (on radial, femoral, brachial artery) -> introduce the sheath -> guiding catheter -> visualization by x-ray -> coronary guide wire (with radiopaque flexible tip) -> angioplasty/ballon catheter -> inflation of ballon

Question 6

Stenting: use

Answer 6

• used to keep the arteries of a patient open

Question 7

Stenting: different types of stents

Answer 7

• bare metal stent (the traditional) -> prevents narrowing
• Drug eluting stents -> Sirolimus, everolimus, paclitaxel, used in 3/4 of PCIs with stenting -> are stents coated with drugs to prevent stenosis/thrombus formation. It suppresses tissue growth and local immune modulation.

Question 8

Anticoagulant regimens -> applied to angioplasty (during + after)

Answer 8

Used reduces risk of thrombosis

• clopidogrel + GP IIb/IIIa inhibitors -> NSTEMI (unstable)
• clopidogrel + ASA for 9-12 months after a PCI

Question 9

Relative contraindications:

Answer 9

• coagulopathy
• hyper coagulable state
• diffusely diseased vessels without focal stenosis
• single diseased vessel providing all perfusion to the myocardium
• total occlusion of coronary artery
• stenosis < 50%

Question 10

PCI advantages

Answer 10

• low risk

- patient is awake

Question 11

PCI disadvantages

Answer 11

• risk of recurrent angina
• bleeding from insertion point (bruise + hematoma)
• allergy reactions
• restenosis can happen, but less likely to occur with the drug eluting stents