Preparation of the patient for PCI

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Patient Information

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 approaches

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

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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). "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" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. doi:10.1016/j.jacc.2011.08.006. PMID 22070837. Retrieved 2011-12-08. Text "PDF" ignored (help); Unknown parameter |month= ignored (help)
  2. ↑ 2.0 2.1 Smith SC, Feldman TE, Hirshfeld JW, Jacobs AK, Kern MJ, King SB; et al. (2006). "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 (ACC/AHA/SCAI Writing Committee to Update 2001 Guidelines for Percutaneous Coronary Intervention)". Circulation. 113 (7): e166–286. doi:10.1161/CIRCULATIONAHA.106.173220. PMID 16490830.
  3. ↑ Feit F, Brooks MM, Sopko G, Keller NM, Rosen A, Krone R et al. (2000)Long-term clinical outcome in the Bypass Angioplasty Revascularization Investigation Registry: comparison with the randomized trial. BARI Investigators. Circulation101 (24):2795-802. PMID: [1]
  4. ↑ King SB, Barnhart HX, Kosinski AS, Weintraub WS, Lembo NJ, Petersen JY et al. (1997) or surgery for multivessel coronary artery disease: comparison of eligible registry and randomized patients in the EAST trial and influence of treatment selection on outcomes. Emory Angioplasty versus Surgery Trial Investigators.Am J Cardiol 79 (11):1453-9. PMID:9185632
  5. ↑ 5.0 5.1 Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ et al. (2009)Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 360 (10):961-72.DOI:10.1056/NEJMoa0804626 PMID:19228612
  6. ↑ Chakravarty T, Buch MH, Naik H, White AJ, Doctor N, Schapira J et al. (2011)Predictive accuracy of SYNTAX score for predicting long-term outcomes of unprotected left main coronary artery revascularization. Am J Cardiol 107 (3):360-6.DOI:10.1016/j.amjcard.2010.09.029 PMID:21256999
  7. ↑ Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson TB, Dziuban SW et al. (2001)A decade's experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases.Ann Surg 234 (4):464-72; discussion 472-4. PMID: 11573040
  8. ↑ Kim YH, Park DW, Kim WJ, Lee JY, Yun SC, Kang SJ et al. (2010)Validation of SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score for prediction of outcomes after unprotected left main coronary revascularization. JACC Cardiovasc Interv 3 (6):612-23.DOI:10.1016/j.jcin.2010.04.004PMID:20630454
  9. ↑ Morice MC, Serruys PW, Kappetein AP, Feldman TE, Ståhle E, Colombo A et al. (2010)Outcomes in patients with de novo left main disease treated with either percutaneous coronary intervention using paclitaxel-eluting stents or coronary artery bypass graft treatment in the Synergy Between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) trial. Circulation 121 (24):2645-53.DOI:10.1161/CIRCULATIONAHA.109.899211 PMID:[2]
  10. ↑ Shahian DM, O'Brien SM, Filardo G, Ferraris VA, Haan CK, Rich JB et al. (2009)The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1--coronary artery bypass grafting surgery. Ann Thorac Surg 88 (1 Suppl):S2-22.[3] PMID: 19559822
  11. ↑ Shahian DM, O'Brien SM, Normand SL, Peterson ED, Edwards FH (2010)Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score. J Thorac Cardiovasc Surg 139 (2):273-82.DOI:10.1016/j.jtcvs.2009.09.007 PMID:[4]
  12. ↑ Welke KF, Peterson ED, Vaughan-Sarrazin MS, O'Brien SM, Rosenthal GE, Shook GJ et al. (2007)Comparison of cardiac surgery volumes and mortality rates between the Society of Thoracic Surgeons and Medicare databases from 1993 through 2001. Ann Thorac Surg 84 (5):1538-46. [5] PMID: [6]
  13. ↑ Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, Mintz GS, Lansky AJ, Moses JW, Stone GW, Leon MB, Dangas G (2004). "A simple risk score for prediction of contrast-induced nephropathy after percutaneous coronary intervention: development and initial validation". Journal of the American College of Cardiology. 44 (7): 1393–9. doi:10.1016/j.jacc.2004.06.068. PMID 15464318. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  14. ↑ Moscucci M, Rogers EK, Montoye C, Smith DE, Share D, O'Donnell M, Maxwell-Eward A, Meengs WL, De Franco AC, Patel K, McNamara R, McGinnity JG, Jani SM, Khanal S, Eagle KA (2006). "Association of a continuous quality improvement initiative with practice and outcome variations of contemporary percutaneous coronary interventions". Circulation. 113 (6): 814–22. doi:10.1161/CIRCULATIONAHA.105.541995. PMID 16461821. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  15. ↑ Bader BD, Berger ED, Heede MB, Silberbaur I, Duda S, Risler T, Erley CM (2004). "What is the best hydration regimen to prevent contrast media-induced nephrotoxicity?". Clinical Nephrology. 62 (1): 1–7. PMID 15267006. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  16. ↑ Mueller C, Buerkle G, Buettner HJ, Petersen J, Perruchoud AP, Eriksson U, Marsch S, Roskamm H (2002). "Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty". Archives of Internal Medicine. 162 (3): 329–36. PMID 11822926. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  17. ↑ Solomon R, Werner C, Mann D, D'Elia J, Silva P (1994). "Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents". The New England Journal of Medicine. 331 (21): 1416–20. doi:10.1056/NEJM199411243312104. PMID 7969280. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  18. ↑ Trivedi HS, Moore H, Nasr S, Aggarwal K, Agrawal A, Goel P, Hewett J (2003). "A randomized prospective trial to assess the role of saline hydration on the development of contrast nephrotoxicity". Nephron. Clinical Practice. 93 (1): C29–34. PMID 12411756. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  19. ↑ Marenzi G, Assanelli E, Campodonico J, Lauri G, Marana I, De Metrio M, Moltrasio M, Grazi M, Rubino M, Veglia F, Fabbiocchi F, Bartorelli AL (2009). "Contrast volume during primary percutaneous coronary intervention and subsequent contrast-induced nephropathy and mortality". Annals of Internal Medicine. 150 (3): 170–7. PMID 19189906. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  20. ↑ 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". The American Journal of Medicine. 103 (5): 368–75. PMID 9375704. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  21. ↑ Russo D, Minutolo R, Cianciaruso B, Memoli B, Conte G, De Nicola L (1995). "Early effects of contrast media on renal hemodynamics and tubular function in chronic renal failure". Journal of the American Society of Nephrology : JASN. 6 (5): 1451–8. PMID 8589322. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  22. ↑ Gonzales DA, Norsworthy KJ, Kern SJ, et al. A meta-analysis of N-acetylcysteine in contrast-induced nephrotoxicity: unsupervised clustering to resolve heterogeneity. BMC Med. 2007; 5: 32. Published online November 14, 2007. doi:10.1186/1741-7015-5-32
  23. ↑ Ozcan EE, Guneri S, Akdeniz B, et al. Sodium bicarbonate, N-acetylcysteine, and saline for prevention of radiocontrast-induced nephropathy. A comparison of 3 regimens for protecting contrast-induced nephropathy in patients undergoing coronary procedures. A single-center prospective controlled trial. Am Heart J. 2007; 154: 539– 44.
  24. ↑ Thiele H, Hildebrand L, Schirdewahn C, et al. Impact of high-dose N-acetylcysteine versus placebo on contrast-induced nephropathy and myocardial reperfusion injury in unselected patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: the LIPSIA-N-ACC (Prospective, Single-Blind, Placebo-Controlled, Randomized Leipzig Immediate PercutaneouS Coronary Intervention Acute Myocardial Infarction N-ACC) Trial. J Am Coll Cardiol. 2010; 55: 2201– 9.
  25. ↑ Webb JG, Pate GE, Humphries KH, et al. A randomized controlled trial of intravenous N-acetylcysteine for the prevention of contrast-induced nephropathy after cardiac catheterization: lack of effect. Am Heart J. 2004; 148: 422–9.
  26. ↑ ACT Investigators. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-Induced Nephropathy Trial (ACT). Circulation. 2011; 124: 1250–9.
  27. ↑ Klein LW, Sheldon MW, Brinker J, et al. The use of radiographic contrast media during PCI: a focused review: a position statement of the Society of Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2009; 74: 728– 46.
  28. ↑ Levine GN, Kern MJ, Berger PB, et al. Management of patients undergoing percutaneous coronary revascularization. Ann Intern Med. 2003; 139: 123– 36.
  29. ↑ Tramer MR, von Elm E, Loubeyre P, et al. Pharmacological prevention of serious anaphylactic reactions due to iodinated contrast media: systematic review. BMJ. 2006; 333: 675.
  30. ↑ Greenberger PA, Patterson R, Tapio CM. Prophylaxis against repeated radiocontrast media reactions in 857 cases. Adverse experience with cimetidine and safety of beta-adrenergic antagonists. Arch Intern Med. 1985; 145: 2197– 200.
  31. ↑ Shehadi WH. Adverse reactions to intravascularly administered contrast media. A comprehensive study based on a prospective survey. Am J Roentgenol Radium Ther Nucl Med. 1975; 124: 145– 52.
  32. ↑ Gill BV, Rice TR, Cartier A, et al. Identification of crab proteins that elicit IgE reactivity in snow crab-processing workers. J Allergy Clin Immunol. 2009; 124: 1055– 61.
  33. ↑ Swoboda I, Bugajska-Schretter A, Verdino P, et al. Recombinant carp parvalbumin, the major cross-reactive fish allergen: a tool for diagnosis and therapy of fish allergy. J Immunol. 2002; 168: 4576– 84.
  34. ↑ Briguori C, Colombo A, Airoldi F, Violante A, Focaccio A, Balestrieri P, Paolo Elia P, Golia B, Lepore S, Riviezzo G, Scarpato P, Librera M, Bonizzoni E, Ricciardelli B (2004). "Statin administration before percutaneous coronary intervention: impact on periprocedural myocardial infarction". European Heart Journal. 25 (20): 1822–8. doi:10.1016/j.ehj.2004.07.017. PMID 15474697. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  35. ↑ Briguori C, Visconti G, Focaccio A, Golia B, Chieffo A, Castelli A, Mussardo M, Montorfano M, Ricciardelli B, Colombo A (2009). "Novel approaches for preventing or limiting events (Naples) II trial: impact of a single high loading dose of atorvastatin on periprocedural myocardial infarction". Journal of the American College of Cardiology. 54 (23): 2157–63. doi:10.1016/j.jacc.2009.07.005. PMID 19664895. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  36. ↑ Pasceri V, Patti G, Nusca A, Pristipino C, Richichi G, Di Sciascio G (2004). "Randomized trial of atorvastatin for reduction of myocardial damage during coronary intervention: results from the ARMYDA (Atorvastatin for Reduction of MYocardial Damage during Angioplasty) study". Circulation. 110 (6): 674–8. doi:10.1161/01.CIR.0000137828.06205.87. PMID 15277322. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  37. ↑ Patti G, Pasceri V, Colonna G, Miglionico M, Fischetti D, Sardella G, Montinaro A, Di Sciascio G (2007). "Atorvastatin pretreatment improves outcomes in patients with acute coronary syndromes undergoing early percutaneous coronary intervention: results of the ARMYDA-ACS randomized trial". Journal of the American College of Cardiology. 49 (12): 1272–8. doi:10.1016/j.jacc.2007.02.025. PMID 17394957. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  38. ↑ Yun KH, Jeong MH, Oh SK, Rhee SJ, Park EM, Lee EM, Yoo NJ, Kim NH, Ahn YK, Jeong JW (2009). "The beneficial effect of high loading dose of rosuvastatin before percutaneous coronary intervention in patients with acute coronary syndrome". International Journal of Cardiology. 137 (3): 246–51. doi:10.1016/j.ijcard.2008.06.055. PMID 18706705. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  39. ↑ Zhang F, Dong L, Ge J (2010). "Effect of statins pretreatment on periprocedural myocardial infarction in patients undergoing percutaneous coronary intervention: a meta-analysis". Annals of Medicine. 42 (3): 171–7. doi:10.3109/07853890903463976. PMID 20384433. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  40. ↑ Winchester DE, Wen X, Xie L, Bavry AA (2010). "Evidence of pre-procedural statin therapy a meta-analysis of randomized trials". Journal of the American College of Cardiology. 56 (14): 1099–109. doi:10.1016/j.jacc.2010.04.023. PMID 20825761. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  41. ↑ Di Sciascio G, Patti G, Pasceri V, Gaspardone A, Colonna G, Montinaro A (2009). "Efficacy of atorvastatin reload in patients on chronic statin therapy undergoing percutaneous coronary intervention: results of the ARMYDA-RECAPTURE (Atorvastatin for Reduction of Myocardial Damage During Angioplasty) Randomized Trial". Journal of the American College of Cardiology. 54 (6): 558–65. doi:10.1016/j.jacc.2009.05.028. PMID 19643320. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  42. ↑ Aversano T, Aversano LT, Passamani E, Knatterud GL, Terrin ML, Williams DO, Forman SA (2002). "Thrombolytic therapy vs primary percutaneous coronary intervention for myocardial infarction in patients presenting to hospitals without on-site cardiac surgery: a randomized controlled trial". JAMA : the Journal of the American Medical Association. 287 (15): 1943–51. PMID 11960536. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  43. ↑ 43.0 43.1 Dehmer GJ, Blankenship J, Wharton TP, Seth A, Morrison DA, Dimario C, Muller D, Kellett M, Uretsky BF (2007). "The current status and future direction of percutaneous coronary intervention without on-site surgical backup: an expert consensus document from the Society for Cardiovascular Angiography and Interventions". Catheterization and Cardiovascular Interventions : Official Journal of the Society for Cardiac Angiography & Interventions. 69 (4): 471–8. doi:10.1002/ccd.21097. PMID 17278155. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  44. ↑ Melberg T, Nilsen DW, Larsen AI, Barvik S, Bonarjee V, Kuiper KK, Nordrehaug JE (2006). "Nonemergent coronary angioplasty without on-site surgical backup: a randomized study evaluating outcomes in low-risk patients". American Heart Journal. 152 (5): 888–95. doi:10.1016/j.ahj.2006.06.026. PMID 17070152. Retrieved 2011-12-06. Unknown parameter |month= ignored (help)
  45. ↑ Singh PP, Singh M, Bedi US, Adigopula S, Singh S, Kodumuri V, Molnar J, Ahmed A, Arora R, Khosla S (2011). "Outcomes of nonemergent percutaneous coronary intervention with and without on-site surgical backup: a meta-analysis". American Journal of Therapeutics. 18 (2): e22–8. doi:10.1097/MJT.0b013e3181bc0f5a. PMID 19918168. Retrieved 2011-12-06.

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