Percutaneous transluminal coronary angioplasty (PTCA) was first introduced by Andreas Gruentzig in 1977 as an alternative to coronary bypass surgery. The concept was initially demonstrated by Charles Dotter in 1964 in peripheral vessels. The development of a small inelastic balloon catheter by Gruentzig allowed expansion of the technique into smaller peripheral and coronary vessels. Initial coronary experience was limited to single-vessel coronary disease and discrete proximal lesions due to the technical limitations of the equipment. Advances in technology and greater operator experience allowed the procedure to grow rapidly with expanded use in patients with more complex lesions and multivessel disease. The introduction of coronary stents in 1994 was one of the major advances in the field. These devices reduced acute complications and reduced by half the significant problems of acute thrombosis and late restenosis (or recurrence of the stenosis). Further reductions in restenosis were achieved by the introduction of drug-eluting stents in 2003. These stents slowly release antiproliferative drugs directly into the plaque over a few months. Percutaneous coronary intervention (PCI) is the most common revascularization procedure in the United States and is performed more than twice as often as coronary artery bypass surgery: nearly 900,000 patients a year.
Interventional cardiology is a separate discipline in cardiology that requires a dedicated 1-year interventional cardiology fellowship following a 3-year general cardiology fellowship in order to obtain a separate board certification. The discipline has also expanded to include interventions for structural heart disease including treatment of congenital heart disease and valvular heart disease; it also includes interventions to treat peripheral vascular disease, including atherosclerotic and nonatherosclerotic lesions in the carotid, renal, aortic, and peripheral arterial and venous circulations.
The initial procedure is performed in a similar manner as a diagnostic cardiac catheterization (Chap. 237). Arterial access is obtained via the femoral or radial artery. To prevent thrombotic complications during the procedure, patients who are anticipated to need an angioplasty are given aspirin (325 mg) and may be given a platelet P2Y12 inhibitor such as clopidogrel (loading dose of 600 mg), prasugrel (loading dose of 60 mg), or ticagrelor (loading dose of 180 mg) before the procedure. Cangrelor, an IV P2Y12 inhibitor, is approved for use in patients who have not received an oral agent prior to the procedure. During the procedure, anticoagulation is achieved by administration of unfractionated heparin, enoxaparin (a low-molecular-weight heparin), or bivalirudin (a direct thrombin inhibitor). In patients with ST-elevation myocardial infarction, high-risk acute coronary syndrome, or a large thrombus in the coronary artery, an intravenous glycoprotein IIb/IIIa inhibitor (abciximab, tirofiban, or eptifibatide) may also be given, though cangrelor may be as effective with less bleeding risk.
Following placement of an introducing sheath into the artery, preformed guiding catheters are used to cannulate selectively the origins of the coronary arteries. Through the guiding catheter, a flexible, steerable guidewire is negotiated down the coronary artery lumen using ...