Preparation of the patient for PCI

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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 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. [7]

Overview

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.

Preparation of the Patient for PCI

Premedications

  1. Aspirin
  2. Clopidogrel

2011 and 2005 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[1][2]

Heart Team Approach to Revascularization Decisions (DO NOT EDIT)[1]

Class I

"1. A Heart Team approach to revascularization is recommended in patients with unprotected left main or complex CAD. [3][4][5] (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. [5][6][7][8][9][10][11][12] (Level of Evidence: B)"

Contrast-Induced Acute Kidney Injury (DO NOT EDIT)[1]

Class I

"1. Patients should be assessed for risk of contrast-induced acute kidney injury before PCI.[13][14] (Level of Evidence: C)"

"2. Patients undergoing cardiac catheterization with contrast media should receive adequate preparatory hydration.[15][16][17][18] (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.[19][20][21] (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.[22][23] [24][25][26] (Level of Evidence: A)"

Anaphylactoid Reactions (DO NOT EDIT)[1]

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. [27][28][29][30](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. [31][32][33](Level of Evidence: C)"

Statin Treatment (DO NOT EDIT)[1]

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) [34][35][36][37][38][39][40];(Level of Evidence: B for those on chronic statin therapy) [41]"

Bleeding Risk (DO NOT EDIT)[1]

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)[1]

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.[42][43] (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.[43][44][45] (Level of Evidence: B)"

Role of Onsite Cardiac Surgical Back-Up (DO NOT EDIT)[2]

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)"

References

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