Percutaneous coronary intervention (PCI) is the most widely employed coronary revascularization procedure worldwide (Chap. 246). It is now applied to patients with stable angina, acute coronary syndromes, including unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI), and as a primary treatment strategy in patients with ST-segment elevation myocardial infarction (STEMI). PCI is also applicable to patients with either single- or multi-vessel disease.
In this chapter, the use of PCI will be illustrated in a variety of commonly encountered clinical and anatomic situations such as chronic total occlusion of a coronary artery, bifurcation disease, acute STEMI, saphenous vein graft disease, left main coronary artery disease, multivessel disease, and stent thrombosis. In addition, the use of interventional techniques to treat structural heart disease will be shown, including closure of an atrial septal defect (ASD) and percutaneous aortic valve implantation; the latter is approved in Europe but is under active investigation in clinical trials in the United States and not yet approved for use.
- An 81-year-old man with angina, NYHA Class IV congestive heart failure and inferior-apical-posterior ischemia on an exercise technetium-99m scan.
- Diagnostic cardiac catheterization revealed a left dominant system with a totally occluded left circumflex (LCx) artery. The distal LCx filled via collaterals from the left anterior descending (LAD) artery, indicating chronicity of the total occlusion.
Baseline left coronary angiogram shows an occluded LCx with left-to-left collaterals originating from LAD septal vessels.
Attempts to cross the total occlusion in the LCx using a hydrophilic wire and an antegrade approach were not successful, with the wire tracking to the right of the trajectory.
The LAD septal collateral is accessed with a guidewire and directed toward the distal LCx to cross the total occlusion retrograde.
The total occlusion is crossed retrograde. The wire is snared in the guide, exteriorized, and used to provide antegrade access to the LCx.
Antegrade flow in the LCx is restored after balloon inflation.
Following stenting of the total occlusion, blood flow in the distal vessel is improved and a second significant stenosis is seen.
Final result after LCx stenting.
- Approximately 15–30% of all patients referred for cardiac catheterization will have a chronic total occlusion (CTO) of a coronary artery.
- CTO often leads to a surgical referral for complete revascularization.
- Incomplete revascularization due to an untreated CTO is associated with an increased mortality rate (Hazard Ratio = 1.36, 95% CI = 1.12–1.66, p < 0.05).
- Successful PCI of a CTO leads to a 3.8–8.4% absolute reduction in mortality, symptom relief, and improved left ventricular function.
- Newer techniques, such as the retrograde approach to crossing total occlusions, are useful when the antegrade approach fails, or is not feasible, and there are well-developed collateral vessels.
(Case contributed with permission by Dr. Frederick G. P. Welt)
(Fig. e33-1; Videos e33-8 to e33-16)
- A 52-year-old man with an acute coronary syndrome and a troponin I = 0.18 (upper limit normal ≤ 0.04).
- Diagnostic cardiac catheterization showed single-vessel coronary artery disease with a significant stenosis in the mid-LAD and a bifurcation lesion involving a large diagonal branch.
Schematic representation of 1-stent and 2-stent techniques to treat bifurcation lesions. (Reprinted with permission from SK Sharma and A Kini: Cardiol Clin 24:233, 2006.)
Baseline angiogram of the left coronary circulation shows the significant stenosis in the mid-LAD and the bifurcation lesion involving a large diagonal branch.
Both vessels are accessed with guidewires and pretreated with balloon angioplasty.
Result after balloon angioplasty.
Stent being positioned in the LAD.
Stent deployed in diagonal branch through the stent struts in the LAD using the "culotte" technique.
Diagonal branch post-stent result.
Simultaneous inflation of two 2.5-mm "kissing" balloons.
Final postbifurcation stenting result.
- Approximately 15–20% of PCIs will involve the treatment of bifurcation lesions.
- Bifurcation lesions require consideration of PCI strategies that protect side-branch patency.
- There are both one-stent and two-stent techniques to treat bifurcation lesions; the selection of technique depends upon anatomic considerations, including plaque burden, angle of side-branch take-off, plaque shift during angioplasty, and side-branch distribution.
- Rates of target lesion revascularization and stent thrombosis are similar between one-stent and two-stent procedures.
(Figs. e33-2 to e33-4; Videos e33-17 to e33-22)
- A 59-year-old man presented to the emergency room with 2 h of severe midsternal chest pressure.
- His systolic blood pressure was 100 mmHg and he was tachycardic in sinus rhythm with a heart rate of 90–100 bpm.
- His ...
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