Percutaneous coronary intervention can produce excellent results in carefully selected patients who may have one or more severely narrowed artery segments which are suitable for balloon dilatation, stenting, or atherectomy.

Percutaneous coronary intervention is performed in a special room fitted with computerized X-ray equipment called a cardiac catheterization laboratory. Patients are mildly sedated with small amounts of diazepam, midazolam, morphine, and other sedative narcotics given intravenously. During percutaneous coronary intervention, a local anesthetic is injected into the skin over the artery in the groin or arm. The artery is punctured with a needle and a plastic sheath is placed into the artery. Under x-ray guidance (fluoroscopy), a long, thin plastic tube, called a guiding catheter, is advanced through the sheath to the origin of the coronary artery from the aorta. A contrast dye containing iodine is injected through the guiding catheter so that x-ray images of the coronary arteries can be obtained. A small diameter guide wire (0.014 inches) is threaded through the coronary artery narrowing or blockage. A balloon catheter is then advanced over the guide wire to the site of the obstruction. This balloon is then inflated for about one minute, compressing the plaque and enlarging the opening of the coronary artery. Finally, the balloon is deflated and removed from the body.

Intracoronary stents are delivered over a conventional angioplasty balloon. When the balloon is inflated, the stent is expanded and deployed, and the balloon is removed. The stent remains in place in the artery. Atherectomy devices are inserted into the coronary artery over a standard angioplasty guide wire, and then activated in varying fashion, depending on the device chosen.

The percutaneous coronary intervention procedure can last from 30 minutes to two hours, but is usually completed within 60 minutes.

 

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Patients are then brought to a monitored bed for observation. The plastic catheters left in the artery are removed from the groin after four to 12 hours depending on how long blood thinning is needed to stabilize the opened artery. When these catheters are removed, the area is compressed by hand or with the aid of a mechanical clamp for about 20 minutes to prevent bleeding. In many instances, the artery in the groin may be sutured or “sealed” in the catheterization laboratory, and the catheters are immediately removed. This enables the patient to sit up in bed within a few hours after the procedure.

Most patients are discharged home the day after percutaneous coronary intervention. Patients are advised not to lift anything heavier than 20 pounds or perform vigorous exertion for the first one to two weeks after percutaneous coronary intervention. This allows the area in the coronary artery as well as the groin or arm arteries to heal. Patients may return to normal work and sexual activity two or three days after percutaneous coronary intervention.

Complications of PCI

Percutaneous coronary intervention, using balloons, stents, and/or atherectomy can achieve effective relief of coronary arterial obstruction in 90% to 95% of patients. In a very small percentage of individuals, percutaneous coronary intervention cannot be performed because of technical difficulties. These difficulties usually involve the inability to pass the guide wire or the balloon catheter across the narrowed artery segments. The most serious complication of percutaneous coronary intervention results when there is an abrupt closure of the dilated coronary artery within the first few hours after the procedure. Abrupt coronary artery closure occurs in 5% of patients after simple balloon angioplasty, and is responsible for most of the serious complications related to percutaneous coronary intervention. Abrupt closure is due to a combination of tearing (dissection) of the inner lining of the artery, blood clotting (thrombosis) at the balloon site, and constriction (spasm) or elastic recoil of the artery at the balloon site.

To help prevent the process of thrombosis during or after percutaneous coronary intervention, aspirin is given to prevent platelets from adhering to the artery wall and stimulating the formation of blood clots. Intravenous heparin or synthetic analogues of part of the heparin molecule is given to further prevent blood clotting; and combinations of nitrates and calcium blockers are used to minimize vessel spasm. Individuals at an increased risk for abrupt closure include: women, Individuals with unstable angina, and individuals having heart attacks. The incidence of abrupt occlusion after percutaneous coronary intervention has declined dramatically with the introduction of coronary stents, which essentially eliminate the problem of flow-limiting arterial dissections, elastic recoil, and spasm. The use of new intravenous “super aspirins”, which alter platelet function at a site different from the site of aspirin-inhibition, have dramatically reduced the incidence of thrombosis after balloon angioplasty and stenting.

When despite these measures, a coronary artery cannot be “kept open” during percutaneous coronary intervention, emergency CABG surgery may be necessary. Before the advent of stents and advanced anti-thrombotic strategies, emergency CABG following a failed percutaneous coronary intervention was required in as many as 5% of patients. In the current era, the need for emergent CABG following percutaneous coronary intervention is less than 1%.The overall acute mortality risk following percutaneous coronary intervention is less than one percent; the risk of a heart attack following percutaneous coronary intervention is only about 1% to 2%. The degree of risk is dependent on the number of diseased vessels treated, the function of the heart muscle, and the age and clinical condition of the patient.

 

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