copyright © 2011 american heart association. percutaneous coronary intervention sripal bangalore,...

Copyright © 2011 American Heart Association.

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


OverviewOverview

Percutaneous Coronary Intervention Indications Contraindications / Caution Equipment Technique Precautions Guide catheter selection Guidewire selection Guidewire: Tips & tricks Complications

Dissection Perforation

IndicationsIndicationsAsymptomatic Ischemia or CCS Class I or II Angina (Class I and III only)

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

No Class I indication

PCI is not recommended in patients with asymptomatic ischemia or CCS class I or II angina who have 1 or more of the following:

Only a small area of viable myocardium at risk

No objective evidence of ischemia

Lesions that have a low likelihood of successful dilatation

Mild symptoms that are unlikely to be due to myocardial ischemia

Factors associated with increased risk of morbidity or mortality

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

IndicationsIndicationsCCS Class III Angina (Class I and III only)


No Class I indication

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:

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


IndicationsIndicationsPatients With UA/NSTEMI (Class I and III only)


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: Recurrent ischemia despite intensive anti-ischemic therapy Elevated troponin level New ST-segment depression Heart failure symptoms or new or worsening MR Depressed LV systolic function Hemodynamic instability Sustained ventricular tachycardia PCI within 6 months Prior CABG

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: 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


IndicationsIndicationsPatients With STEMI (Class I and III only)


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)

Primary PCI should be performed as quickly as possible, with a goal of a medical contact-to-balloon or door-to-balloon time within 90 minutes.

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

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)


IndicationsIndicationsPatients With STEMI (Class I and III only)


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

Primary PCI should not be performed in asymptomatic patients more than 12 hours after onset of STEMI who are hemodynamically and electrically stable


IndicationsIndicationsPCI for Cardiogenic Shock (Class I and III only)


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

IndicationsIndicationsPatients With Prior Coronary Bypass Surgery (Class I and III only)


When technically feasible, PCI should be performed in patients with early ischemia (usually within 30 days) after CABG

It is recommended that distal embolic protection devices be used when technically feasible in patients undergoing PCI to saphenous vein grafts

PCI is not recommended in patients with prior CABG for chronic total vein graft occlusions

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



There are no absolute contraindications to PCI.

Relative contraindications include:

Coagulopathy (Radial approach can be attempted based on urgency)

Decompensated congestive heart failure

Uncontrolled Hypertension

Pregnancy

Inability for patient cooperation

Active infection

Renal Failure

Contrast medium allergy

ContraindicationsContraindications


Conscious sedation using a narcotic and a benzodiazepine

Vascular access: femoral (described in the section on vascular access and closure devices), radial, or brachial

Antiplatelet therapy with aspirin and a thienopyridine (clopidogrel or prasugrel)

Antithrombotic therapy with either unfractionated heparin, low molecular weight heparin, or bivalirudin

Glycoprotein receptor IIB/IIIA inhibitors can be used based on the procedure

Flush the selected guiding catheter (connected to a Y-port) with saline to ensure an air free system

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

Equipment & TechniqueEquipment & Technique


Once in the ascending aorta, the guidewire is removed, the catheter allowed to bleed back to remove any thrombus or atherosclerotic debris

The catheter is then connected to a manifold assembly connected to a pressure transducer for continuous central pressure monitoring

The guiding catheter is flushed to ensure an air free system

The guiding catheter should then be filled with 3-4 cc of contrast and advanced to engage the coronary ostium, in the LAO projection

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

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

At this stage, in the setting of thrombotic STEMI lesions, a manual aspiration catheter can be used to aspirate thrombus

TechniqueTechnique


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)

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

The balloon is then removed

Pre-dilatation should be avoided in SVG grafts (if possible) to prevent distal embolization

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

This is advanced over the guidewire, across the lesion and deployed by inflating the balloon mounted stent to appropriate pressures

The stent balloon is now removed and coronary angiography performed to ensure no complications and to assess for adequate stent expansion

TechniqueTechnique


Some laboratories believe in routine post-dilatation of all stents (except SVG interventions) to ensure adequate strut expansion

If desired, this is accomplished by using a non-compliant balloon of appropriate size and length

The balloon is removed and coronary angiography performed in two orthogonal views assessing the following:

Stent and the proximal and distal edge to ensure no dissections or perforation

The distal wire site to ensure no perforation

The ostium to ensure no dissection caused by the guiding catheter

The guidewire is then removed and angiography is performed to confirm adequate stent deployment and no complications as described above

The guiding catheter should then be removed and intravenous antithrombotic therapy stopped unless further continuation is required due to heavy thrombus burden

TechniqueTechnique


Depending on the support provided by the guide catheter, they can be divided into the following 3 types:

Standard guide catheters which do not provide any additional support. Examples: JL4, JR4, etc.

Support guide catheters - these rest in the sinus of valsalva and provide more support than the standard guide catheters. Examples: AL, AR, etc.

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.

Coronary stenting can be performed using 4 to 6Fr guide catheters

Larger guide catheters (7-8Fr) are needed for more complex procedures- bifurcation stenting, rotational atherectomy, to provide extra support for chronic total occlusions or tortuous and calcified lesions

Guide Catheter SelectionGuide Catheter Selection


Coronary guidewires are usually 0.010-0.018in diameter with the most commonly used being 0.014in made of stainless steel or nitinol

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

Based on support Soft Moderate support Extra support - For chronic total occlusions Super extra support - For chronic total occlusions

Coronary Guidewire SelectionCoronary Guidewire Selection


Always start with the least traumatic wire (‘work horse’ wire)

Always advance the wire under fluoroscopic guidance

Never allow the guidewire tip to buckle (more prone to dissection)

Always ensure that the wire tip is free

If on wire advancement, frequent PVC’s are noted, wire tip might have perforated and may be irritating the myocardium. Withdraw the wire.

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

For stenting over a bifurcation with a wire protecting the branch vessel, always deploy the stent at low pressures, withdraw the branch wire, re-cross 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

Coronary Guidewire: Tips & TricksCoronary Guidewire: Tips & Tricks


Apart from the complications listed under diagnostic coronary angiography, those related to PCI include

Abrupt closure and dissections

Perforation

Intramural hematoma

Side branch occlusion

Distal embolization

Stroke

Non-fatal MI

Death

Emergent CABG

Others: ventricular arrhythmia, acute renal failure, radiation injury

ComplicationsComplications


Usually due to balloon dilatation injury, during guidewire passage, or trauma due to the guiding catheter

Types:

Type A — Luminal haziness

Type B — Linear dissection

Type C — Extraluminal contrast staining

Type D — Spiral dissection

Type E — Dissection with reduced flow

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

Complications: DissectionsComplications: Dissections


Usually due to guidewire exit, over-aggressive balloon dilation or stent deployment, and rarely due to cutting balloon angioplasty or during rotational atherectomy

Types:

Class I - intramural crater without extravasation

Class II - pericardial or myocardial blushing (staining)

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

Stop anticoagulation and consider reversal

Inflate balloon or a perfusion balloon to tamponade the site of perforation

Contra-lateral arterial access with an 8F sheath

Complications: PerforationComplications: Perforation


Severe perforation treatment (continued):

If patient is hemodynamically unstable, perform pericardiocentesis immediately

Drain blood and autotransfuse into a central vein

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)

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

Complications: PerforationComplications: Perforation

copyright © 2011 american heart association. percutaneous coronary intervention sripal bangalore,...

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