1. Copyright © 2011 American Heart Association. Percutaneous Coronary Intervention Sripal Bangalore, M.D., M.H.A. and Deepak L. Bhatt, M.D., M.P.H., F.A.H.A

2. Copyright © 2011 American Heart Association. Overview Percutaneous Coronary Intervention  Indications  Contraindications / Caution  Equipment  Technique  Precautions  Guide catheter selection  Guidewire selection  Guidewire: Tips & tricks  Complications  Dissection  Perforation

3. Indications Asymptomatic Ischemia or CCS Class I or II Angina (Class I and III only) I I I IIa IIb III I I I IIa IIb III I I I IIa IIb III IIa IIb III  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

4. Indications CCS Class III Angina (Class I and III only) I I I IIa IIb III I I I IIa IIb III I I I IIa IIb III IIa IIb III  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 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

5. Indications Patients With UA/NSTEMI (Class I and III only) I I I IIa IIb III I I I IIa IIb III I I I IIa IIb III IIa IIb III  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 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

6. Indications Patients With STEMI (Class I and III only) I I I IIa IIb III I I I IIa IIb III I I I IIa IIb III IIa IIb III  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) 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

7. Indications Patients With STEMI (Class I and III only) I I I IIa IIb III I I I IIa IIb III I I I IIa IIb III IIa IIb III  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 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

8. Indications PCI for Cardiogenic Shock (Class I and III only) I I I IIa IIb III I I I IIa IIb III I I I IIa IIb III IIa IIb III  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

9. Indications Patients With Prior Coronary Bypass Surgery (Class I and III only) I I I IIa IIb III I I I IIa IIb III I I I IIa IIb III IIa IIb III  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 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

10. Copyright © 2011 American Heart Association.  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 Contraindications

11. Copyright © 2011 American Heart Association.  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 & Technique

12. Copyright © 2011 American Heart Association.  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 Technique

13. Copyright © 2011 American Heart Association.  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 Technique

14. Copyright © 2011 American Heart Association.  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 Technique

15. Copyright © 2011 American Heart Association.  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 Selection

16. Copyright © 2011 American Heart Association.  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 Selection

17. Copyright © 2011 American Heart Association.  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 & Tricks

18. Copyright © 2011 American Heart Association.  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 Complications

19. Copyright © 2011 American Heart Association.  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: Dissections

20. Copyright © 2011 American Heart Association.  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: Perforation

21. Copyright © 2011 American Heart Association.  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: Perforation