Percutaneous coronary intervention (PCI) is a non-surgical procedure
used to treat narrowing (stenosis) of the coronary arteries of the
heart found in coronary artery disease. After accessing the blood
stream through the femoral or radial artery, the procedure uses
coronary catheterization to visualise the blood vessels on X-ray
imaging. After this, an interventional cardiologist can perform a
coronary angioplasty, using a balloon catheter in which a deflated
balloon is advanced into the obstructed artery and inflated to relieve
the narrowing; certain devices such as stents can be deployed to keep
the blood vessel open. Various other procedures can also be performed.
Primary PCI is the very urgent use of PCI in people with acute
myocardial infarction (heart attack), especially where there is
evidence of severe heart damage on the electrocardiogram (ST elevation
MI). PCI is also used in people after other forms of myocardial
infarction or unstable angina where there is a high risk of further
events. Finallly, PCI may be used in people with stable angina
pectoris, particularly if the symptoms are difficult to control with
medication. PCI is an alternative to coronary artery bypass grafting
(CABG, often referred to as "bypass surgery"), which bypasses stenotic
arteries by grafting vessels from elsewhere in the body. Under certain
circumstances (extensive blockages, background of diabetes), CABG may
Coronary angioplasty was first introduced in 1977 by Andreas Gruentzig
1 Medical uses
2 Adverse events
3.1 Types of stent
4.1 Comparison to CABG
9 External links
Coronary angiography and angioplasty in acute myocardial infarction
(left: RCA closed, right: RCA successfully dilated)
Tight, critical stenosis (95%) of the proximal LAD in a patient with
PCI is used primarily to open a blocked coronary artery and restore
arterial blood flow to heart tissue, without requiring open-heart
surgery. In patients with a restricted or blocked coronary artery, PCI
may be the best option to re-establish blood flow as well as prevent
angina (chest pain), myocardial infarctions (heart attacks) and death.
Today, PCI usually includes the insertion of stents, such as
bare-metal stents, drug-eluting stents, and fully resorbable vascular
scaffolds (or naturally dissolving stents). The use of stents has been
shown to be important during the first three months after PCI; after
that the artery can remain open on its own. This is the premise for
developing bioresorbable stents that naturally dissolve after they are
no longer needed.
The appropriateness of PCI use depends on many factors. PCI may be
appropriate for patients with stable coronary artery disease if they
meet certain criteria, such as having any coronary stenosis greater
than 50 percent or having angina symptoms that are unresponsive to
medical therapy. Although PCI may not provide any greater help in
preventing death or myocardial infarction over oral medication for
patients with stable coronary artery disease, it likely provides
better relief of angina.
In patients with acute coronary syndromes, PCI may be appropriate;
guidelines and best practices are constantly evolving. In patients
with severe blockages, such as ST-segment elevation myocardial
infarction (STEMI), PCI can be critical to survival as it reduces
deaths, myocardial infarctions and angina compared with medication.
For patients with either non-ST-segment elevation myocardial
infarction (nSTEMI) or unstable angina, treatment with medication
and/or PCI depends on a patient's risk assessment. The
door-to-balloon time is used as a quality measure for hospitals to
determine the timeliness of primary PCI.
The use of PCI in addition to anti-angina medication in stable
angina may reduce the number of patients with angina attacks for up
to 3 years following the therapy, but does not reduce the risk of
death, future myocardial infarction or need for other
Coronary angioplasty is widely practiced and has a number of
risks; however, major procedural complications are uncommon.
Coronary angioplasty is usually performed using invasive
catheter-based procedures by an interventional cardiologist, a medical
doctor with special training in the treatment of the heart.
The patient is usually awake during angioplasty, and chest discomfort
may be experienced during the procedure. The patient remains awake in
order to monitor the patient's symptoms. If symptoms indicate the
procedure is causing ischemia the cardiologist may alter or abort part
of the procedure. Bleeding from the insertion point in the groin
(femoral artery) or wrist (radial artery) is common, in part due to
the use of antiplatelet drugs. Some bruising is therefore to be
expected, but occasionally a hematoma may form. This may delay
hospital discharge as flow from the artery into the hematoma may
continue (pseudoaneurysm) which requires surgical repair. Infection at
the skin puncture site is rare and dissection (tearing) of the access
blood vessel is uncommon.
Allergic reaction to the contrast dye used
is possible, but has been reduced with the newer agents. Deterioration
of kidney function can occur in patients with pre-existing kidney
disease, but kidney failure requiring dialysis is rare. Vascular
access complications are less common and less serious when the
procedure is performed via the radial artery.
The most serious risks are death, stroke, ventricular fibrillation
(non-sustained ventricular tachycardia is common), myocardial
infarction (heart attack, MI), and aortic dissection. A heart attack
during or shortly after the procedure occurs in 0.3% of cases; this
may require emergency coronary artery bypass surgery.
injury characterized by elevated levels of CK-MB, troponin I, and
troponin T may occur in up to 30% of all PCI procedures. Elevated
enzymes have been associated with later clinical outcomes such as
higher risk of death, subsequent MI, and need for repeat
Angioplasty carried out shortly
after an MI has a risk of causing a stroke, but this is less than the
risk of a stroke following thrombolytic drug therapy.
As with any procedure involving the heart, complications can
sometimes, though rarely, cause death. The mortality rate during
angioplasty is 1.2%. Sometimes chest pain can occur during
angioplasty because the balloon briefly blocks off the blood supply to
the heart. The risk of complications is higher in:
People aged 65 and older
People who have kidney disease or diabetes
People who have poor pumping function in their hearts
People who have extensive heart disease and blockages
The term balloon angioplasty is commonly used to describe percutaneous
coronary intervention, which describes the inflation of a balloon
within the coronary artery to crush the plaque into the walls of the
artery. While balloon angioplasty is still done as a part of nearly
all percutaneous coronary interventions, it is rarely the only
Other procedures done during a percutaneous coronary intervention
Implantation of stents
Rotational or laser atherectomy
Brachytherapy (use of radioactive source to inhibit restenosis)
The angioplasty procedure usually consists of most of the following
steps and is performed by a team made up of physicians, physician
assistants, nurse practitioners, nurses, radiographers, and
endovascular specialists; all of whom have extensive and specialized
training in these types of procedures.
Access into the femoral artery in the leg (or, less commonly, into the
radial artery or brachial artery in the arm) is created by a device
called an "introducer needle". This procedure is often termed
Once access into the artery is gained, a "sheath introducer" is placed
in the opening to keep the artery open and control bleeding.
Through this sheath, a long, flexible, soft plastic tube called a
"guiding catheter" is pushed. The tip of the guiding catheter is
placed at the mouth of the coronary artery. The guiding catheter also
allows for radio-opaque dyes (usually iodine-based) to be injected
into the coronary artery, so that the disease state and location can
be readily assessed using real time X-ray visualization.
During the X-ray visualization, the cardiologist estimates the size of
the coronary artery and selects the type of balloon catheter and
coronary guidewire that will be used during the case.
"blood thinner" or medicine used to prevent the formation of clots) is
given to maintain blood flow.
Bivalirudin when used instead of heparin
has a higher rate of myocardial infarction but lower rates of
The coronary guidewire, which is an extremely thin wire with a
radio-opaque flexible tip, is inserted through the guiding catheter
and into the coronary artery. While visualizing again by real-time
X-ray imaging, the cardiologist guides the wire through the coronary
artery to the site of the stenosis or blockage. The tip of the wire is
then passed across the blockage. The cardiologist controls the
movement and direction of the guidewire by gently manipulating the end
that sits outside the patient through twisting of the guidewire.
While the guidewire is in place, it now acts as the pathway to the
stenosis. The tip of the angioplasty or balloon catheter is hollow and
is then inserted at the back of the guidewire—thus the guidewire is
now inside of the angioplasty catheter. The angioplasty catheter is
gently pushed forward, until the deflated balloon is inside of the
The balloon is then inflated, and it compresses the atheromatous
plaque and stretches the artery wall to expand.
If a stent was on the balloon, then it will be implanted (left behind)
to support the new stretched open position of the artery from the
Types of stent
A coronary stent placed by percutaneous coronary intervention.
Traditional bare-metal stents (BMS) provide a mechanical framework
that holds the artery wall open, preventing stenosis, or narrowing, of
Newer drug-eluting stents (DES) are traditional stents with a polymer
coating containing drugs that prevent cell proliferation. The
antiproliferative drugs are released slowly over time to help prevent
tissue growth — which may come in response to the stent — that can
block the artery. These types of stents have been shown to help
prevent restenosis of the artery through physiological mechanisms that
rely upon the suppression of tissue growth at the stent site and local
modulation of the body’s inflammatory and immune responses. The
first two drug-eluting stents to be utilized were the
paclitaxel-eluting stent and the sirolimus-eluting stent, both of
which have received approval from the U.S. Food and Drug
Administration. Most current FDA-approved drug-eluting stents use
sirolimus (also known as rapamycin), everolimus and zotarolimus.
Biolimus A9-eluting stents, which utilize biodegradable polymers, are
approved outside the U.S.
However, in 2006, clinical trials showed a possible connection between
drug-eluting stents and an event known as “late stent thrombosis”
where the blood clotting inside the stent can occur one or more years
after stent implantation. Late stent thrombosis occurs in 0.9% of
patients and is fatal in about one-third of cases when the thrombosis
occurs. Increased attention to antiplatelet medication duration
and new generation stents (such as everolimus-eluting stents) have
dramatically reduced concerns about late stent thrombosis.
Newer-generation PCI technologies aim to reduce the risk of late stent
thrombosis or other long-term adverse events. Some DES products market
a biodegradable polymer coating with the belief that the permanent
polymer coatings of DES contribute to long-term inflammation. Other
strategies: A more recent study proposes that, in the case of
population with diabetes mellitus—a population particularly at
risk—a treatment with paclitaxel-eluting balloon followed by BMS may
reduce the incidence of coronary restenosis or myocardial infarction
compared with BMS administered alone.
After placement of a stent or scaffold, the patient needs to take two
antiplatelet medications (aspirin and one of a few other options) for
several months to help prevent blood clots. The ideal length of time a
patient needs to be on dual antiplatelet therapy is not fully
determined, but guidelines recommend continuing for 12 months beyond
placement unless a patient is at a high risk for bleeding.
In primary PCI, angiography may demonstrate thrombus (blood clots)
inside the coronary arteries. Various studies have been performed to
determine whether aspirating these clots (thrombus aspiration or
manual thrombectomy) is beneficial. At the moment there is no evidence
that routine clot aspiration improves outcomes.
Percutaneous coronary angioplasty is one of the most common procedures
performed during U.S. hospital stays; it accounted for 3.6% of all
operating room procedures performed in 2011. Between 2001 and
2011, however, its volume decreased by 28%, from 773,900 operating
procedures performed in 2001 to 560,500 procedures in 2011.
Comparison to CABG
Most studies have found that CABG offers advantages in reducing death
and myocardial infarction in people with multivessel blockages
compared with PCI. Different modeling studies have come to
opposing conclusions on the relative cost-effectiveness of PCI and
CABG in people with myocardial ischemia that does not improve with
Main article: History of invasive and interventional cardiology
Coronary angioplasty, also known as percutaneous transluminal coronary
angioplasty (PTCA), because it is done through the skin and through
the lumen of the artery, was first developed in 1977 by Andreas
Gruentzig. The first procedure took place Friday Sept 16, 1977, at
Zurich, Switzerland. Adoption of the procedure accelerated
subsequent to Gruentzig's move to
Emory University in the United
States. Gruentzig's first fellow at Emory was Merril Knudtson, who, by
1981, had already introduced it to Calgary, Alberta, Canada. By
the mid-1980s, many leading medical centers throughout the world were
adopting the procedure as a treatment for coronary artery disease.
Angioplasty is sometimes erroneously referred to as "Dottering", after
Interventional Radiologist, Dr Charles Theodore Dotter, who, together
with Dr Melvin P. Judkins, first described angioplasty in 1964. As
the range of procedures performed upon coronary artery lumens has
widened, the name of the procedure has changed to percutaneous
coronary intervention.
Current concepts recognize that after three months the artery has
adapted and healed and no longer needs the stent. Complete
revasculariztion of all stenosed coronary arteries after a STEMI is
more efficacious in terms of major adverse cardiac events and
all-cause mortality, while being safer than culprit-vessel-only
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In 2007 the
New England Journal of Medicine
New England Journal of Medicine published the results of a
trial called COURAGE. The study compared stenting as used in PCI
to medical therapy alone in symptomatic stable coronary artery disease
(CAD). This showed there was no mortality advantage to stenting in
stable CAD, though there was earlier relief of symptoms which
equalized by five years. After this trial there were widely publicized
reports of individual doctors performing PCI in patients who did not
meet any traditional criteria. A 2014 meta-analysis showed there
may be improved mortality with second generation drug-eluting stents,
which were not available during the COURAGE trial. Medical
societies have since issued guidelines as to when it is appropriate to
perform percutaneous coronary intervention. In response the
rate of inappropriate stenting was seen to have declined between 2009
and 2014. Statistics published related to the trends in U.S.
hospital procedures, showed a 28% decrease in the overall number of
PCIs performed in the period from 2001 to 2011, with the largest
decrease notable from 2007. One study found that symptom relief in
people with stable angina after percutaneous coronary intervention is
similar to placebo.
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Q&A: Primary angioplasty, 18 Oct 2008
Percutaneous Coronary Intervention - Patient UK
Percutaneous Coronary Intervention - Medscape
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Percutaneous aortic valve replacement
Mitral valve replacement
production of septal defect in heart
enlargement of existing septal defect
creation of septal defect in heart
shunt from heart chamber to blood vessel
atrium to pulmonary artery
left ventricle to aorta
right ventricle to pulmonary artery
for transposition of great vessels
for univentricular defect
shunt from blood vessel to blood vessel
systemic circulation to pulmonary artery shunt
SVC to the right PA
Coronary artery bypass
Valve-sparing aortic root replacement
Alcohol septal ablation
Cox maze and minimaze
Left atrial appendage occlusion
Implantable loop recorder
Cardiac stress test
Myocardial perfusion imaging
Cardiac catheterization/Coronary catheterization