Basics of pci
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Coronary heart disease is a major cause of mortality worldwide. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a non-surgical procedure used to treat blockages within the coronary arteries of the heart. During PCI, a catheter is inserted into an artery and guided to the site of blockage where a balloon is inflated to open the artery. Often a stent is placed to keep the artery open. PCI has become a common revascularization treatment for acute coronary syndromes and stable angina. While generally safe, complications from PCI occur in less than 2% of patients and include adverse reactions, acute myocardial infarction, bleeding, and death in less than 0.08% of patients.
Basics of pci
- 1. Basics of Percutaneous Coronary Intervention Dr Waseem A Siddiqui, MD, MBBS
- 2. EPIDEMIOLOGY CORONARY HEART DISEASE (CHD) Major causes of morbidity and mortality all over the world In 2016, American Heart Association (AHA) reported that 15.5 million persons > 20 years of age in USA have CHD, & prevalence increases with age Every 42 seconds, an American suffers from MI1 CHD mortality declined over the last decades in western countries, it is expected to continue increasing in developing countries2 Age-standardized CVD death rate is 272/ 100 000 population in India, which is higher than global average of 235 per 100 000 population.2 Current estimates from epidemiologic studies show prevalence of CHD 7-13% in urban and 2-7% in rural area.3 1. https://www.ncbi.nlm.nih.gov/pubmed/22929818 2. https://www.ncbi.nlm.nih.gov/pubmed/?term=cardiovascular+disease+in+India.+Current+Epidemiology+and+Future+directions 3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860846
- 3. TREATMENT MODALITIES Lifestyle Modification & Risk factor Management : Smoking , Exercise, Weight Control, Management of DM, HTN and Hyperlipidaemia Pharmacological therapy : Antiplatelet and antianginal drugs Surgical Management (Revascularization): Percutaneous Coronary Intervention(PCI) Coronary Artery Bypass Grafting (CABG) http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/cardiology/coronary-artery-disease
- 4. PERCUTANEOUS CORONARY INTERVENTIONS Percutaneous coronary interventions (PCI) include percutaneous transluminal coronary angioplasty (PTCA) with or without stent insertion First performed in human by Andreas Gruentzig in 1971 Most commonly performed interventional procedure PTCA and stent placement within 90 min of onset of pain is the optimal treatment of transmural ST- segment–elevation myocardial infarction (STEMI). Elective PCI may be appropriate for post-MI patients who have recurrent or inducible angina before hospital discharge and for patients who have angina and remain symptomatic despite medical treatment. Michael J. Shea. Percutaneous Coronary Interventions. MSDManual. Feb, 2016
- 5. INDICATIONS Acute ST-elevation myocardial infarction (STEMI) Non–ST-elevation acute coronary syndrome (NSTE- ACS) Unstable angina Stable angina Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness or syncope) High risk stress test findings CONTRAINDICATION S • Coagulopathy • Decompensated congestive heart failure • Uncontrolled Hypertension • Pregnancy • Inability for patient cooperation • Active infection • Renal Failure • Contrast mediumGeorge A Stouffer, at al. Percutaneous Coronary Intervention (PCI). Drug and disease,
- 6. TYPES OF PCI IN ACS WITH STEMI Primary PCI: Procedure is performed within 12 hours after the onset of symptoms. Rescue PCI: Rescue PCI is recommended if thrombolysis failed within 45-60 min after starting the administration Post thrombolysis PCI: Thrombolysis-facilitated primary PCI Ischaemia guided PCI: Ischaemia-driven PCI after thrombolysis Ali Ghanie. Indication for Percutaneous Coronary Angioplasty. Acta Med Indones-Indones J Intern Med. 2009; 41: 159-65
- 7. EQUIPMENTS Balloon catheters for PCI have the following features: A steerable guide wire precedes balloon into artery & permits navigation through coronary tree Inflation of balloon compresses & axially redistributes atheromatous plaque & stretches vessel wall Balloon catheter also serves as adjunctive device for many other interventional therapies Intracoronary stents have the following features: Stents differ with respect to composition, design, delivery system & drug delivered Drug-eluting stents (DESs) have demonstrated significant reductions in re-stenosis & target-lesion revascularization rates, with further reduction with second-generation DESs In the United States, commercially available DESs are second-generation models that elute everolimus & zotarolimus Both stents with bio-absorbable polymer & fully bioresorbable scaffolds Stents are conventionally placed after balloon predilation, but in selected coronary lesions, direct stenting may lead to better outcomes George A Stouffer, at al. Percutaneous Coronary Intervention (PCI). Drug and disease, Oct. 16.
- 8. PROCEDURE PCI is done via percutaneous femoral, radial, or brachial artery puncture. Radial approach is technically demanding compared to the femoral approach but may reduce patient discomfort, improve time to ambulation, and reduce the incidence of some complications (eg, bleeding, pseudoaneurysm formation). A guiding catheter is inserted into a large peripheral artery and threaded to appropriate coronary ostium. A balloon-tipped catheter, guided by fluoroscopy or intravascular ultrasonography, is aligned within the stenosis, then inflated to disrupt the atherosclerotic plaque and dilate the artery. Angiography is repeated after the procedure to document any changes. The procedure is commonly done in 2 or 3 vessels as needed. Michael J. Shea. Percutaneous Coronary Interventions. MSDManual. Feb, 2016
- 9. ANTICOAGULATION & ANCILLARY THERAPY Antithrombotic therapy: Aspirin (162-325 mg) F/B Unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), or bivalirudin used at the time of balloon angioplasty or PCI. Antiplatelet therapy Thienopyridines (clopidogrel, prasugrel, ticagrelor) and glycoprotein IIb/IIIa inhibitors (abciximab, eptifibatide, tirofiban) are the standard of care for patients with unstable non-ST-segment elevation myocardial infarction for at least 9 to 12 months after PCI. Glycoprotein inhibitor therapy Abciximab, tirofiban, and eptifibatide reduce ischemic complications in patients undergoing balloon angioplasty and coronary stenting. Calcium channel blockers and nitrates may also reduce risk of coronary spasm. Michael J. Shea. Percutaneous Coronary Interventions. MSDManual. Feb, 2016
- 10. STENT TYPES • Latest type of coronary stent • Contains a drug with active healing technology(helps in healing process of artery) • Has coating both sides DUAL THERAPY STENT • Drug eluting stent with a dissolvable type of scaffold – absorbed overtime • Coated with drug released from polymer • Reduces the chances of restenosis BIORESORBABLE VASCULAR SCAFFOLD • Antibody coated stent • Does not contain a polymer or drug • Speeds up the epithelialization of the artery—promoted natural healing BIO-ENGINEERED STENT DRUG ELUTING STENT BARE METAL STENT https://www.orbusneich.com/en/patient/types-coronary-stents-0 • Stainless steel, without special coating • As artery heals, tissue grows around stent holding it in place • Overgrowth of scar tissue-↑ risk of re-blockage • Coated with medications that help to prevent the growth of scar tissue in the artery lining • ↑ chances of blood clots– stent thrombosis
- 11. COMPICATIONS MAJOR • Allergic & Adverse reaction (30%) • Acute MI requiring emergency CABG (5-30%) • Distal embolization (<2%) • Nephropathy (3.3-16.5%) • Hematoma and Retroperitoneal Hemorrhage (2.8%) • Pseudoaneurysm (0.5-2.0%) • Arterio-venous Fistula (1%) • Ventricular arrhythmia (1.3-3.5%) MINOR • Cerebrovascular Complications (0.07-0.23%) • Abrupt closure and dissections (0.42% ) • Radiation injury • Hypotension • Hypoglycemia • Death (0.08-1%) • Infection (<1%) Morteza Tavakol, et al. Risks and Complications of Coronary Angiography: A Comprehensive Review. Glob J Health Sci. 2012 Jan; 4(1): 65–93 Major complications from PIC occur in <2% of the population, with mortality of <0.08%
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