Staged PCI

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: delayed PCI

Overview

Staged PCI or delayed PCI is referred to the performance of a percutaneous coronary intervention (PCI) at a later date separate from the performance of the diagnostic catheterization or the performance of an initial PCI. Ad hoc PCI is defined as performance of the PCI procedure immediately following diagnostic catheterization [1]. Same day PCI is defined as removing the patient from the cardiac catheterization laboratory following the procedure, and then performing the PCI procedure later in the day. Databases usually do not allow a distinction between "Ad hoc PCI" and "Same day PCI". As a result there is no data regarding the prevalence or the impact of same day PCI.

Historical Perspective

When PCI was first developed, the risk of requiring urgent coronary artery bypass grafting (CABG) surgery was approximately 5%, and this necessitated the availability of onsite CABG. AS PCI became safer and more predictable, it was more frequently performed immediately following the diagnostic cardiac catheterization ("ad hoc PCI").

Advantages of Staged PCI

More detailed informed consent can be provided regarding the proposed revascularization procedure and the potential alternatives such as CABG. Patients who are at risk of contrast induced acute tubular necrosis (patients over age 65, patients with diabetes, patients with impaired renal function), may benefit from a staged PCI procedure by minimizing the dye load required during two separate procedures.

Risk Factors for Contrast Induced Nephropathy

Three factors have been associated with an increased risk of contrast-induced nephropathy: pre-existing renal insufficiency (such as Creatinine clearance < 60 mL/min [1.00 mL/s] - online calculator), pre-existing diabetes, and reduced intravascular volume.[2][3] A clinical prediction rule is available to estimate probability of nephropathy (increase ≥25% and/or ≥0.5 mg/dl in serum creatinine at 48 h)[4] based upon the following risk factors:

  • 2 for 40–60 mL/min/1.73 m2
  • 4 for 20–40 mL/min/1.73 m2
  • 6 for < 20 mL/min/1.73 m2

Scoring:

5 or less points

  • Risk of CIN - 7.5
  • Risk of Dialysis - 0.04%

6–10 points

  • Risk of CIN - 14.0
  • Risk of Dialysis - 0.12%

11–16 points

  • Risk of CIN - 26.1*
  • Risk of Dialysis - 1.09%

>16 points

  • Risk of CIN - 57.3
  • Risk of Dialysis - 12.8%

Disadvantages of Staged PCI

The disadvantages of staged PCI include the following:

  1. The patient must be instrumented twice with the attendant risk of bleeding and trauma to the vessel.
  2. The patient must return to the hospital for the procedure on a separate occasion which is inconvenient.
  3. A payor must pay for a separate procedure.

Efficacy and Safety of Staged PCI

There are no randomized trials of staged versus ad hoc PCI and only registry data is available for comparison. it should be noted that registry data does not adjust for unidentified confounders. There are seven registry is that compare ad hoc and staged PCI and there are no differences in the angiographic success rates either in the era of conventional balloon angioplasty [5][6][7][8][9][10][11] or in the era of stenting [12][13][14][15][16][17] In one registry experience, the rates of vascular complications were lower in the patients undergoing ad hoc PCI [18]

Prevalence of Ad Hoc PCI

Ad hoc PCI is currently performed in approximately 60% to 96% of patients and the proportion of patients continues to increase.[19][20][21][22][23][24][25]

Guidelines Regarding Staged PCI

Performance of PCI in a non-culprit artery at the time of a ST elevation MI (STEMI) is a class III contraindication. Only 2% of interventional cardiologist would perform a PCI in a non-culprit vessel in the setting of STEMI in a patient who is hemodynamically stable [26]. The need for and the timing of staged PCI among patients with unstable angina (UA) or non ST elevation MI (NSTEMI) and stable angina is less clear.

Timing of a Staged PCI

STEMI

1. In the setting of STEMI, ad hoc PCI of the culprit artery is recommended if the patient presents within 12 hours of symptoms.[27]

2. 62% of interventional cardiologists recommend that the PCI of the non-culprit artery be performed more than 15 days after the STEMI [28].

3. Among STEMI patients with cardiogenic shock ad hoc PCI is appropriate.[29] If the culprit lesion cannot be identified with certainty in the setting, then PCI of more than one lesion may be appropriate. Although PCI of a non-culprit lesion is inappropriate in the absence of cardiogenic shock and may be associated with worse outcomes,[30] PCI of a non-culprit vessel may be appropriate if there is a flow limiting lesion and cardiogenic shock persists following PCI the culprit vessel.

UA / NSTEMI

There is less of a consensus regarding the optimal timing of a staged PCI among UA / NSTEMI patients. 55% of surveyed cardiologists recommend waiting > 2 weeks following the initial revascularization to perform the next PCI, while 22% recommended that the additional PCI be performed during the same hospitalization as the initial revascularization.

Stable Angina

Among patients with stable angina, 64% of surveyed cardiologist recommend waiting ≥ 15 days to perform the second PCI following the initial revascularization while 35% recommend performance of PCI within 2 weeks of the initial revascularization.

Clinical Scenarios Favoring Delayed Percutaneous Coronary Intervention

In a SCAI consensus statement, the following scenarios may favor the performance of staged PCI[31]:

“

1. High-risk/complex anatomic stable coronary disease (e.g., unprotected left main, complex multivessel coronary artery disease, chronic total occlusion).

2. Excessive contrast or radiation during diagnostic procedure or anticipated during percutaneous coronary intervention.

3. Site of service (e.g., facility without onsite surgery in which the patient risk or lesion risk is high or facility lacking necessary interventional equipment).

4. Inadequate informed consent (e.g., diagnostic catheterization identifies anatomy for which the risk of PCI is significantly higher than was discussed before percutaneous coronary intervention).

5. Uncertainty regarding extent of symptoms in patients with stable ischemic heart disease.

6. Lack of evidence of ischemia and unavailability of fractional flow reserve or intravascular ultrasound.

7. Complication during diagnostic catheterization (e.g., stroke and access site bleeding).

8. Operator or patient fatigue after diagnostic catheterization.

9. Scheduling problems (e.g., if a new patient presents with ST-elevation as ad hoc PCI is being considered for a patient with stable ischemic heart disease).

10. Inadequate pretreatment (e.g., no aspirin before diagnostic catheterization, inadequate trial of antianginal therapy, and inadequate hydration).

”

The Appropriate Use Criteria [32] indicate that a PCI should not be performed if a patient does not have severe symptoms, if they have not undergone prior functional testing to confirm ischemia, or if they are not on optimal medical therapy. Furthermore the Appropriate Use Criteria indicate that either intravascular ultrasound (IVUS) or fractional flow reserve (FFR) can be used as substitutes for noninvasive testing if it was not performed prior to angiography to evaluate the functional significance of the target lesion. Although the appropriate use pretreated does not discuss the timing of procedures, it stands to reason that if the appropriateness of a procedures is uncertain then the procedure should be delayed until the indications are clarified. [33]

Clinical Scenarios Favoring Ad Hoc PCI

1. The presence of an Acute Coronary Syndrome(ACS). [34]

2.The Aprpriate Use Criteria do not explicitly discuss the timing of PCI. Patients with ongoing ischemia, and those with stable moderate/severe angina who are managed with optimal medical therapy (OMT) are deemed suitable candidates for PCI.[35]

References

  1. ↑ Ad Hoc Percutaneous Coronary Intervention: A Consensus Statement From the Society for Cardiovascular Angiography and Interventions http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CDkQFjAB&url=http%3A%2F%2Fwww.scai.org%2Fasset.axd%3Fid%3Dc985cb20-a31b-4e82-a688-2f82be854b21&ei=FD7KUMXwKKay0AHEp4CACg&usg=AFQjCNH2rTxEcgSgaigX_lYvSvML2u7E-A&bvm=bv.1355272958,d.dmQ
  2. ↑ McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW (1997). "Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality". Am J Med. 103 (5): 368–75. PMID 9375704.
  3. ↑ Scanlon PJ, Faxon DP, Audet AM, Carabello B, Dehmer GJ, Eagle KA, Legako RD, Leon DF, Murray JA, Nissen SE, Pepine CJ, Watson RM, Ritchie JL, Gibbons RJ, Cheitlin MD, Gardner TJ, Garson A Jr, Russell RO Jr, Ryan TJ, Smith SC Jr (1999). "ACC/AHA guidelines for coronary angiography. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions". J Am Coll Cardiol. 33 (6): 1756–824. PMID 10334456.
  4. ↑ Mehran R, Aymong ED, Nikolsky E; et al. (2004). "A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation". J. Am. Coll. Cardiol. 44 (7): 1393–9. doi:10.1016/j.jacc.2004.06.068. PMID 15464318.
  5. ↑ O’Keefe JH, Reeder GS, Miller GA, Bailey KR, Holmes DR. Safety and efficacy of percutaneous transluminal coronary angioplasty performed at time of diagnostic catheterization compared with that performed at other times. Am J Cardiol 1989;63:27–29.
  6. ↑ O’Keefe JH, Gernon C, McCallister BD, Ligon RW, Hartzler GO. Safety and cost effectiveness of ad hoc coronary angiography and angioplasty. Am Heart J 1991;122:50–54.
  7. ↑ Lund GK, Nienaber CA, Hamm CW, Terres W, Kuck KH. One session diagnostic heart catheterization and balloon dilatation (‘‘prima-vista’’-PTCA): Results and risks. Dtsch Med Wochenschr 1994;119:169–174.
  8. ↑ Rozenman Y, Gilon D, Zelingher J, Lotan C, Mosseri M, Geist M, Weiss AT, Hasin Y, Gotsman MS. One-stage coronary angiography and angioplasty. Am J Cardiol 1995;75:30–33.
  9. ↑ Kimmel SE, Berlin JE, Hennessy S, Strom BL, Krone RJ, Laskey WK. Risk of major complications from coronary angioplasty performed immediately after diagnostic coronary angiography: Results from the Registry of the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol 1997;30:193–200.
  10. ↑ Le Feuvre C, Helft G, Beygui F, Zerah T, Fonseca E, Catuli D, Batisse JP, Metzger JP. Safety, efficacy, and cost advantages of combined coronary angiography and angioplasty. J Interv Cardiol 2003;16:195–199.
  11. ↑ Panchamukhi V, Flaker GC. Should interventional cardiac catheterization procedures take place at the time of diagnostic procedures? Clin Cardiol 2000;23:332–334.
  12. ↑ Shubrooks SJ, Malenka DJ, Piper WD, Bradley WA, Watkins MW, Ryan TJ, Hettleman BD, VerLee PN, O’Meara JR, Robb JF, Kellett MA, Hearne MA, McGrath PD, Wennberg DE, O’Rourke DJ, Silver TM. Safety and efficacy of percutaneous coronary interventions performed immediately after diagnostic catheterization in northern New England and comparison with will Isimilar procedures performed later. Am J Cardiol 2000;86:41–45.
  13. ↑ Goldstein CL, Racz M, Hannan EL. Impact of cardiac catheterization-percutaneous coronary intervention timing on in-hospital mortality. Am Heart J 2002;144:561–567.
  14. ↑ Feldman DN, Minutello RM, Gade CL, Wong SC. Outcomes following immediate (ad hoc) versus staged percutaneous coronary interventions (Report from the 2000 to 2001 New York State Angioplasty Registry). Am J Cardiol 2007;99:446–449.
  15. ↑ Krone RJ, Shaw RE, Klein LW, Blankenship JC, Weintraub WS; American College of Cardiology. Ad hoc percutaneous coronary interventions in patients with stable coronary artery disease—a study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR). Catheter Cardiovasc Interv 2006;68:696–703.
  16. ↑ Hannan EL, Samadashvili Z, Walford G, Holmes DR, Jacobs A, Sharma S, Katz S, King SB. Predictors and outcomes of ad hoc versus non-ad hoc percutaneous coronary interventions. JACC Cardiovasc Interv 2009;2:350–356.
  17. ↑ Good CW, Blankenship JC, Scott TD, Skelding KA, Berger PB, Wood GC. Feasibility and safety of ad hoc percutaneous coronary intervention in the modern era. J Invasive Cardiol 2009;21:194–200.
  18. ↑ Shubrooks SJ, Malenka DJ, Piper WD, Bradley WA, Watkins MW, Ryan TJ, Hettleman BD, VerLee PN, O’Meara JR, Robb JF, Kellett MA, Hearne MA, McGrath PD, Wennberg DE, O’Rourke DJ, Silver TM. Safety and efficacy of percutaneous coronary interventions performed immediately after diagnostic catheterization in northern New England and comparison with will Isimilar procedures performed later. Am J Cardiol 2000;86:41–45.
  19. ↑ Shubrooks SJ, Malenka DJ, Piper WD, Bradley WA, Watkins MW, Ryan TJ, Hettleman BD, VerLee PN, O’Meara JR, Robb JF, Kellett MA, Hearne MA, McGrath PD, Wennberg DE, O’Rourke DJ, Silver TM. Safety and efficacy of percutaneous coronary interventions performed immediately after diagnostic catheterization in northern New England and comparison with will Isimilar procedures performed later. Am J Cardiol 2000;86:41–45.
  20. ↑ Goldstein CL, Racz M, Hannan EL. Impact of cardiac catheterization-percutaneous coronary intervention timing on in-hospital mortality. Am Heart J 2002;144:561–567.
  21. ↑ Feldman DN, Minutello RM, Gade CL, Wong SC. Outcomes following immediate (ad hoc) versus staged percutaneous coronary interventions (Report from the 2000 to 2001 New York State Angioplasty Registry). Am J Cardiol 2007;99:446–449.
  22. ↑ Krone RJ, Shaw RE, Klein LW, Blankenship JC, Weintraub WS; American College of Cardiology. Ad hoc percutaneous coronary interventions in patients with stable coronary artery disease—a study of prevalence, safety, and variation in use from the American College of Cardiology National Cardiovascular Data Registry (ACC-NCDR). Catheter Cardiovasc Interv 2006;68:696–703.
  23. ↑ Hannan EL, Samadashvili Z, Walford G, Holmes DR, Jacobs A, Sharma S, Katz S, King SB. Predictors and outcomes of ad hoc versus non-ad hoc percutaneous coronary interventions. JACC Cardiovasc Interv 2009;2:350–356.
  24. ↑ Good CW, Blankenship JC, Scott TD, Skelding KA, Berger PB, Wood GC. Feasibility and safety of ad hoc percutaneous coronary intervention in the modern era. J Invasive Cardiol 2009;21:194–200.
  25. ↑ Good CW, Blankenship JC, Scott TD, Skelding KA, Berger PB, Wood GC. Feasibility and safety of ad hoc percutaneous coronary intervention in the modern era. J Invasive Cardiol 2009; 21:194–200.
  26. ↑ http://interventions.onlinejacc.org/article.aspx?articleid=1112023
  27. ↑ Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA,Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID,Mukherjee D, Nallamothu BK, Ting HH. 2011 ACCF/AHA/SCAI Guideline for percutaneous coronary intervention: executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines and the society for cardiovascular angiography and interventions. Circulation 2011;124:2574–2609.
  28. ↑ http://interventions.onlinejacc.org/article.aspx?articleid=1112023
  29. ↑ Hochman JS, Sleeper LA, Webb JG, Dzavik V, Buller CE, Aylward P, Col J, White HD. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction.JAMA 2006;295:2511–2515.
  30. ↑ Webb JG, Lowe AM, Sanborn TA, Sleeper LA, Carere RG, Buller CE, Slater JN, Baran KW, Koller PT, Talley D, Porway M, Hochman JS. Percutaneous coronary intervention for cardiogenic shock in the SHOCK trial. J Am Coll Cardiol 2003;42:1380–1386.
  31. ↑ Ad Hoc Percutaneous Coronary Intervention: A Consensus Statement From the Society for Cardiovascular Angiography and Interventions http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CDkQFjAB&url=http%3A%2F%2Fwww.scai.org%2Fasset.axd%3Fid%3Dc985cb20-a31b-4e82-a688-2f82be854b21&ei=FD7KUMXwKKay0AHEp4CACg&usg=AFQjCNH2rTxEcgSgaigX_lYvSvML2u7E-A&bvm=bv.1355272958,d.dmQ
  32. ↑ Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59:857–881.
  33. ↑ Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59:857–881.
  34. ↑ Smith SC Jr, Dove JT, Jacobs AK, Kennedy JW, Kereiakes D, Kern MJ, Kuntz RE, Popma JJ, Schaff HV, Williams DO, Gibbons RJ, Alpert JP, Eagle KA, Faxon DP, Fuster V, Gardner TJ, Gregoratos G, Russel RO. ACC/AHA guidelines of percutaneous coronary interventions (revision of the 1993 PTCA guidelines). J Am Coll Cardiol 2001;37:2215–2239.
  35. ↑ Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Am Coll Cardiol 2012;59:857–881.
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