7. Defining PCI
A PERCUTNEUS CORONRY INTERVANTION(PCI) is
the placement of an angioplasty guideware,baloon or other
device(stent, athrectomy, brachytherapy or thrombectomy
catheter) into a native coronary artery or coronary artery by
pass graft for the purpose of mechanical revascularisation.
Types of PCI
Primary PCI
Resque PCI
Facillated PCI
Elective PCI
8. Evolution of PCI
1844
Bernard coins
the term
“cardiac
catheterization”
1929
Forssmann
peforms the 1st
human cardiac
catheterization
1958
Sones discovers
the diagnostic
coronary
angiogram
1962
Ricketts and
Abrams use the
percutaneous
approach in
coronary
arteries
1964
Dotter
introduces
transluminal
angioplasty
1977
Gruentzig
peforms the 1st
PTCA
1967
Judkins perfects
the transfemoral
approach
1986
Sigwart and Puel
implant the 1st
coronary stent
1994
1st coronary
stent approved
by the FDA 2003
FDA approval of
1st DES
2006
FDA panel on
the safety of
DES
Today
Increasing real-
world use of PCI
in LM and 3VD
2002
CE Mark on 1st
DES
9. Ideally, PCI should be….
Safe (no complications)
Effective (improves QOL and survival)
Predictable (consistent results)
Widely applicable (to all anatomy)
Durable (no restenosis)
10. HISTORY
The first angiogram was performed only few months
after a German Physics Professor Wilhem Conrad
Roentgen's discovery of X rays on 8th nov 1895.
Which was when?
Two physicians injected mercury salts into an amputated
hand and created an image of the arteries
Post mortem injection of mercury salts in Jan,1896.
11. Historical Timeline of Cardiac
Catheterization
1930 Klein reports 11 right-sided heart catheterizations,
and 2 measurements of CO using the Fick equation.
1932 Padillo et al also reports successful right heart
catheterization with CO measurement.
1940-1950s Andre Cournand and Dickinson Richards
report a large series of investigations of right heart
physiology in humans.
1947 Dexter reports his studies on congenital heart disease.
Reports the first catheterization of the distal pulmonary
artery.
1953 Seldinger develops his percutaneous technique of
vascular access.
1959 Dr Mason sones performed selective coronary
arteriography.
12. From Cardiac Cath to PCI
On September 16, 1977, Andreas Grüntzig performed
the first human percutaneous transluminal
coronaryangioplasty(PTCA) in Zurich, Switzerland
with a fixeds-wire,distentensible baloon across a
stenosis in the mid-left anterior descending coronary
artery and briefly inflated it to 6 atm(90psi) .
Over the past 42years, PTCA has evolved into more
sophisticated techniques involving predominantly
stenting and other therapeutic coronary devices is
now called percutaneous coronary intervention (PCI).
13. Percutaneous Coronary interventions(Contd)
Most commonly performed interventional procedure
Percutaneous coronary interventions(PCI) include
percutaneous transluminal coronary
angioplasty(PTCA) with or without stent insertion.
PTCA and stent placement within 90 min of onset
cardiac pain is the optimal treatment of transmural
STMEI
Elective PCI may be approprioate for post MI
patients who have recurrent or inducible angina
before hospital discharge and for patient who have
angina and remain symtomatic despite medical
medical treatment.
14. From Cardiac Cath to PCI(Contd)
PCI was derived from the basic procedures used for
diagnostic cardiac catheterization and coronary
angiography. PCI begins with vascular access by
means of the same techniques for the insertion of an
arterial sheath by Seldinger's method .
In contrast to diagnostic catheters, specialized large-
lumen "guiding" catheters engage the coronary artery
in the same manner but are designed to provide
stabilization or backup for delivery of PCI equipment.
15. No More limited to “coronary interventions”
Techniques and technology used in PCI extend into the
treatment of peripheral arterial disease. Further evolution of
PCI into the treatment of structural heart disease (valves,
septal defects, etc.) is emerging as a separate discipline
within interventional cardiology
17. Cath LabConsist Of
Fluroscopy.
Patient couch.
Image intensifier.
Viewing moniter.
Real time Ecg ,Blood Pressure, Oxygensaturation
measurements
Catheters.
Angioplasty baloon.
Defibrillator.
18. Fluroscopy machine
The x-ray machine is suspended from the ceiling. It
can be manipulated in multiple angles and views to
achive a desired picture.The x-ray comes from the
bottom of the machine and the image intensifier that
transmit the image is above the patient.lead shielding
and a radiation badges required for all personnel in
the room during the procedure.
19. Interventional radiology suite recommended
by ACC
Procedure Room
Room size- 500-600
square feet
Easily cleaned (floors,
wall, etc.)
Outlets needed for O2,
suction.
At least three means of
access.
Control Room
150-200 square feet
Easy access and
communication to
procedure room
Operating console with
Computers, monitors .
20. Coronary artery
The coronary artery is a vasa vasorum that
supply the heart
RIGHT CORONARY
ARTERY
Originates from right
coronary sinus valsalva
Courses through the right
AV groove between the
right atrium and right
ventricle to the inferior
part of the septum
21. Area of distributation of Rt coronary
artery
Right atrium
A greater part of rt ventricle except the area adjoining the
anterior IV groove
A small part of lt ventricle adjoining post IV groove
Posterior part of the IV septum
Whole of the conducting system of the heart except part of
the left branch of AV bundle
22. Coronary artery
LEFT CORONARY ARTERY
Originates from
Lt coronary sinus valsalva.
down the anterior
interventricular
groove-usually reaches
apex.
Branches:LAD,LCX
septals and diagonals
23. Area of distribution of left coronary artery
Left atrium
Greater part of the left ventricle except the area adjoining
the posterior IV groove
A small part of the right ventricle adjoining the anterior IV
groove.
Anterior part of the IV septum
A part of the left branch of the AV bundle.
24. PCI is indicated for patients with
Stable angina pectoris unrelieved by optimal medical
therapy.
Acute myocardial infarction (MI).
Ustable angina.
Angina pectoris after CABG surgery.
Symptomatic restenosis after PCI.
25. Contraindications include:
Bleeding diathesis.
Patient noncompliance with procedure and post-PCI
instructions.
Inability to take dual antiplatelet therapy .
Multiple PCI restenoses.
Unsuitable coronary anatomy.
Decompensated congestive heart failure.
High-risk coronary anatomy in which closure of vessel
would result in death.
26. Atherosclerosi
s is a progressive
inflammatory disorder
of arterial wall that is
characterized by focal
lipid rich deposits of
atheroma that remain
clinically silent until
they become large
enough to impair
tissue perfusion.
28. Catheters
Catheters vary from 100 to 110 cm in length. The 100 cm
catheter is commonly used for LHC’s from the femoral artery
approach.
The outer diameter of the catheter is specified using French
units, where one French unit {F} = 0.33 mm, 6F is 1.98mm in
diameter.
The inner diameter of the catheter is smaller than the
outside diameter owing to the thickness of the catheter
material.
29. Catheters(contd)
Many shapes and sizes.
diameter is given in French(Fr)—3Fr=1mm.
Straight- end hole only—smaller vessels/minimal
contrast.
Pigtail- circular tip with multiple side holes —larger
vessels/ more contrast.
H1 or Head hunter tip– used for femoral approach to
brachiocephalic vessels.
Simmons catheter is highly curved --- for sharply angled
vessels--cerebral and visceral angiography.
C2 or Cobra catheter has angled tip joined to a gentle
curve—celiac, renal & mesenteric arteries
30. Ideal characteristics of catheter
Better Torque Control
Strength
Radiopacity
Flexible
Atraumatic Tip
Trackability
31. Parts of a catheter
HUB
BODY
TIP
Hub
Body
Tip
32. Mearsurements of catheters
FRENCH CATHETER SCALE:
The French catheter scale (Fr, FR or F) is commonly used to
measure the outer diameter of cylindrical medical instruments
including catheters ,needles etc.
D(mm) = Fr/3 or Fr = D(mm)x3
Most commonly in adult Diagnostic Catheters of 5 – 7 Fr is
used.
33. DIFFERENT CATHETER CURVES FOR
DIFFERENT PURPOSES
> Judkins Left (JL)
> Judkins Right ( JR)
> Judkins Left Short Tip
> Judkins Right Short Tip
> Amplatz Left ( AL)
> Amplatz Right ( AR)
> Left Coronary Bypass
> Right Coronary Bypass
> Cardiac Pigtail
> Multipurpose
38. TECHNIQUE OF INSERTING A CATHETER
SELDINGER TECHNIQUE:
Double Wall Puncture
Old original method
: Compression to prevent Hematoma of the other wall.
Single Wall Puncture
New current method
: mostly done
39. SELDINGER TECHNIQUE
Seldinger needle.
18gauge single use,sterile needle.
2 parts-- a solid inner needle(stylet) & an outer thin wall needle
for smooth passage.
a hub---good instrument balance
winged handle---good control.
Site cleaned, area draped, local anesthetic given.
The seldinger needle is introduced into the artery.
When pulsating blood returns, the stylet is removed.
A guide wire is inserted through the needle.
With guide wire in vessel, needle is removed.
Catheter is threaded onto the guide wire.
Under fluoroscope, the catheter is then advanced and the guide
wire is removed.
40.
41. Guidewires
Guidewires are described by:
a)their length in centimeters
b)their diameter in inches
c)their tip confirmation
e.g. a commonly used guidewire is the 145 cm, 0.035 to
0.038-inch, J-tipped wire, available exchange length, 220
cm.
Guide the catheter.
Allow safe introduction of catheter into the vessel.
42. Guidewires (contd)
Made of stainless steel.
Usually about 145cm long
An inner core wire that is tapered at the end to a soft
flexible tip.
Covered by a coating—teflon, heparin and recently
hydrophilic polymers(glide wires) are used.
Coating reduces friction, gives strength to GW.
Tips at the end of GW
Straight
J- tipped—prevents subintimal dissection of artery.
43. 150 cm 0.035” Straight “GLIDEWIRE” with 3 cm
flexible tip.
45. Types of radiocontrast agents
Iodinated radio contrast agents are either ionic or non ionic and
are of variable osmolality .
First generation
Ionic
Highly hyperosmolal(1400to 1800mosmol/kg compared
with the osmolality of plasma).
Second generation
Iohexal
Nonionic monomers.
Low osmolality than first generation,have an increased
osmolality (500 to 800 mosmol/kg compared with the osmolality
of plasma).
The newest nonionic contrast agents:
Iso-osmol,with an osmolality of approximately
290mosmol/kg(iodixanol agent).
46.
47. Angiographic views
Anatomic landmarks formed by the
Spine.
Catheter and diaphragm.
Provide informatio to view the image
In the LAO view the catheter and spine are seen on the left
side of the image,while in the RAO they are found on the
right.
PA imaging places these landmarks in the center. Cranial
can usually be distinguished from caudal angulations by the
presence of the diaphragm. For cranial imaging, the patient
should be asked to inspire to remove the diaphramatic
shadow from the image.
48. Left coronary system
Generaly,for circumfex and proximal epicardial
visualization the Caudal view are most useful
For LAD and LAD/Diagonal bifurcation
visualisation,the cranial views are most useful.
60. 60
Pre-PCI Care(contd)
IV started
Sedation and nausea
Nothing to mouth 4-6 hours before procedure
Records of procedure
PT hemodynamic data
Fluoro times
Medications administered
Supplies used
Other pertinent information
61. Procedure PCI in a nutshell
First a catheter is inserted in the groin or arm. After the
catheter is in place a wire will be guided through the artery
until it reaches the blockage in the heart. A soft, flexible
catheter tube will be slipped over the wire and threaded up
to the blockage.
The doctor will be taking x-ray pictures during the
procedure and dye will be injected into the arteries of the
heart.
Once the blockage is reached, a small balloon at the tip of
the catheter will be rapidly inflated and deflated. This will
stretch the artery open.
The collapsed stent will be inserted. The balloon will be
inflated again to expand the stent to its full size. The stent
will be left in place to hold the vessel walls open. The
deflated balloon, catheter, and wire will be removed.
62. 62
Post PCI Care
Firm pressure is applied to puncture site for 15-30 minutes.
Wound sites are cleaned and dressed.
The patient will be observed in recovery for 4-8 hours .
The insertion site will be checked frequently for signs of
bleeding.
Medications and discharge instructions are given.
Lots of fluid should be taken in.
Vital signs should be monitored for 24 hours.
63. Cath Lab Catastrophes:
Angiographic and Hemodynamic Features
Occluded vessel (large viable area)
Left main dissection
No reflow in a major vessel (SVG)
Poor clearance of dye (aortic root)
Major Perforation / thrombosis/Air embolism
Narrow pulse pressure
Pulmonary hypertension
Worsening metabolic acidosis
65. What is a Stent
A small, mesh-like.
Device made of metal.
Acts as a support or
scaffold, in keeping the vessel open.
Stent helps to improve blood flow to the heart muscle and
reduce the pain of angina.
80% of patients who have balloon angioplasty will have a
stent placed as well.
66. What are DES?
Drug-eluting stents (DES) were introduced into clinical
practice in 2002, in order to reduce restenosis that occurred
in 10–20% of patients receiving bare-metal stents (BMS).
They are stents loaded with drugs that interfere with
pathways in the process of inflammation and neointimal
proliferation.
68. Several types of DES have been
introduced in clinical practice
They are named according to the drug used:
Sirolimus DES
Everolimus DES
Biolimus DES
Zotarolimus DES
Tacrolimus DES
pimecrolimus DES
&Paclitaxel DES
69.
70. Commercial Drug-eluting Stents Systems
TAXUS
Polyolefin derivativePaclitaxel Express2
Drug Polymer Stent
Cypher
PEVA + PBMA blendSirolimus BX Velocity
Endeavor
73. Future Advancements
The ReZolve™ stent integrates a proprietary drug-eluting
polymer and a novel design to create a stent with metal-like
performance out of a polymer material.
The stent restores blood flow and supports the artery
through healing, then completely dissolves from the body,
leaving the patient free of a permanent implant.
74. Future Advancement
Unlike permanent metal alloys, the REVA polymer
dissolves from the body after healing of the artery has
occurred, leaving additional treatment options available in
the future.
Another unique feature of the polymer is that it is visible
under x-ray, allowing the stent to be visualized during the
implant procedure and at follow up. Other bioresorbable
polymer stents are invisible and require permanently
attached radiopaque markers to aid in their placement.
75. A B C
D
G I
FE
J
H
Bifurcation Stents
Newer Interventions and Stents in 2010
76. Various Techniques for Stenting Bifurcation
Lesions
Bifurcation
Lesion
M
V
SB
Stent + PTCA
Stent + stent
(“T stenting”)
Stent + stent
(“Y” or “V”)
“V”2
1
1
Stent + stent
(“Culotte”)
1 2
Stent + stent
(“reverse-T”)
Stent + stent
(“Crush”)
2 1
Stent + stent
(“Kissing”)
78. Mechanisms of stent thrombosis
PATIENT
FACTORS
LESION
FACTORS
PROCEDURAL
& MEDICAL
RX FACTORS
79. Stent thrombosis
Acute occlusion of a previously patent stent.
It is a clinical syndrome (presents with acute coronary
syndrome or sudden death – if silent cannot be defined stent
thrombosis).
It is not due to new plaque rupture at distant site.
There was no severe restenosis with final occlusion.
80. Timing of stent thrombosis
Type Occurrence* Incidence
Acute ≤1 day +(.1%-.9%)
Subacute 2-30 days
+++(8%-
16%)
Late 2-12 months ++
Very late >1 year ++
*after PCI
81. Definition of Stent Thrombosis by Academic
Research Consortium
Definite Stent Thrombosis
Angiographic or pathologic confirmation of partial or total
thrombotic occlusion within the peri-stent region.
AND at least ONE of the following, additional criteria:
- Acute ischemic symptoms.
- Ischemic ECG changes.
- Elevated cardiac biomarkers.
Probable Stent Thrombosis
- Any unexplained death within 30 days of stent implantation.
- Any myocardial infarction, which is related to documented acute
ischemia in the territory of the implanted stent without
angiographic confirmation of stent thrombosis and in the absence
of any other obvious cause.
Possible Stent Thrombosis
- Any unexplained death beyond 30 days.
82. Optimal
Platelet Inhibition
Prevention of Early ST
Extent of
platelet
inhibition
Excess
of
bleeding Prevention of
early ST
Optimal
Procedural Result
No residual dissection
Stent length as short as possible
and as long as needed
Complete stent expansion
83. Restenosis
In-stent restenosis (ISR) defined by a 50% reduction in the
in-stent luminal diameter results from primarily neointimal
proliferation.
Occurs in 30-40% of patients by 6 months after PTCA
Occurs in 10-20% of patients by 6 months after PTCA with
BMS
Restenosis is thought secondary to combination of negative
vessel wall remodeling and neointimal hyperplasia with
smooth muscle cell and matrix proliferation
Elastic recoil and thrombosis may also play a role
85. Restenosis: Mechanism
Elastic recoil: after balloon deflation, the large number of
elastic fibers in the tunica media cause a mechanical
collapse.
Neointimal proliferation (NI): formation of an inner layer at
the site of injury, composed of cells and extracelluler matrix
on the intimal surface.
Negative remodeling: constriction of the vessel by the
formation of a fibrotic scar within the adventitia.
86. Preventing Restenosis
Drug-eluting stents (DES) can deliver anti-proliferative
therapy to the target area without systemic toxicity inhibit
neointimal hyperplasia.
Combined with biologic polymers, drugs are loaded onto
the stent which allows a sustain release.
87. SO
Use DES in
High risk for restenosis
LMCA
Small vessel(<2.5mm diameter)
Long lesion(>20 mm)
bifurcation
Use BMS in
Very low restenosis risk (focal lesion large vessel)
Non-compliant patients
High bleeding risk
Patients requiring surgery
Drug Eluting Stents Are Safe If Applied Appropriately
88. Antiplatelet Therapy and Drug-Eluting Stents
Adequate inhibition of platelet aggregation during and after
PCI.
Compliance with dual antiplatelet therapy particulary during
the first 6-12 months after stent implantation.
Whether dual antiplatelet therapy beyond 12 months
prevents very late ST, is associated with a lower rate of
ischemic cardiovascular events, and has a favorable net
clinical benefit (balance of ischemic vs. bleeding events)
requires confirmation in randomized, prospective trials.
Individualize decision to prolong dual antiplatelet therapy
beyond 6-12 months according to risk profile
diabetes, multivessel disease, previous MI
New platelet inhibitors like Prasugrel/Ticagrelor may
become an attractive alternative to clopidogrel in patients
undergoing PCI.
89. Contrast induced nephropathy(CIN
The intervention cardiology and radiology literature has
traditionally defined contrast induced acute kidney injury as a
rise in serum creatinine of at least 0.5 mg/dL or a 25%
increase from baseline within 48 to 72 hours after contrast
administration in the absence of alternative causes for acute
kidney injury.
91. Prevention of CIN
The use of lower doses of low-or iso-osmolal non ionic
contrast agents
Concomitant nephrotoxic drugs such as NSAIDS and
nephrotoxic antibiotics ACE and diuretics should be
discontinued 48 hours prior to contrast administration
Metformin should be discontinued on the day of the of the
proposed contrast media administration and for the subsequent
48 hours.
In a study by Mueller et al, intravenous administration of
isotonic saline was found to be superior ,compared with half –
isotonic saline in reducing the rates of CIN after percutaneous
coronary intervention(.7% versus 2%,respectively)
92. Interventional Techniques
Treatment of Calcified Lesions
Noncompliant (NC) balloon (high pressure inflation up to
20-24 atm)..
NC balloon with another side-by-side wire in the vessel
and high pressure inflation.
Cutting balloon (up to 8-12 atm).
AngioSculpt® balloon (up to 16-20 atm).
Rotational atherectomy (heavily calcified).
96. Mechanism of No/Slow-flow
Atheromatous debris embolism
Platelet and microthrombi
Platelet activation, aggregation, lysis (by rota burr)
Microcirculatory (vasculature) spasm
Heightened microvasculature reactivity / tone
Microcavitation
Impaired local synthesis of EDRF
Neuro-humoral reflex
Lower epicardial vessel pressure and higher LVEDP
Extreme cases: free radical injury, local edema,
microvascular plugging, no-reflow
Rotational Atherectomy: Complications
EDRF = endothelium-derived relaxing factor; LVEDP = left ventricular end-diastolic
pressure
97. Iartogenic Aortic Dissection
Becoming a more common complication.
Secondary to guide catheter trauma,injection of wedge
catheter or balloon rupture.
Class1:Limited to coronary cusp.
Class2:Limited to cusp and proximal ascending aorta.
Class3:Extending to Aortic Arch.
98. Coronary Dissection Remains a Significant
Problem in the Stent Era
● Plaque fracture (due to balloon
inflation or stent)
● Guide catheter or wire trauma
● Balloon rupture
99. Coronary Perforation Classification
( incidence .19%to1.5%)
Class Description
1 Intraluminal crater without
extravasation
2 Pericardial or myocardial
blush/staining
3 Perforatio>1 mm in diameter with
contrast or cavity spilling
100. Coronary Perforation
- Diagnosis -
● Angiographic (blush, jet, coronary sinus compression,
contrast in pericardium)
● No angiographic evidence in 10-20%
● ECHO (Not needed in 50% at Beaumont)
● Delayed tamponade common (wire induced & IIbIIIa)
105. CORONARY NO-REFLOW PHENOMENON
incidence(.6%-2%)
Coronary no-reflow phenomenon is the inability to perfuse
myocardium after the opening of a previously occluded or
stenosed epicardial coronary artery.
No-reflow phenomenon is suspected to result from a
combination of endothelial damage, platelet and fibrin
embolization,vasospasm, and tissue edema that overwhelms
the coronary microcirculation.
106.
107.
108.
109. Femoral Vs radial
Feature Femoral Radial
Access size bleeding 3 to 4% 0 to .6%
Artery complications Retroperitoneal bl,AV
fistula,Hematoma
Rare local irritation,pulse
loss(3-9%)
Patient comfort Acceptable Great
Ambulation 2-4 hours Immediate
Procedure time and
radiation
short Longer
PVD ,obese Problematic No problem
>8F guide catheters No problem Max 7 F(men)
110. Why Radial? The Advantage
Deceased incidence major entry site complication.
Easier vascular acess and hemostasis for obese patient.
Decease time to ambulation.
Decease post-procedural cost.
Improved patient movement.
