percutaneous coronary intervention (PCI)

Last reviewed 04/2022

Cororary angioplasty is the technique where coronary atheromatous obstructions are dilated by the inflation of a balloon within the artery. The term balloon angioplasty has been now replaced by the term percutaneous coronary intervention (PCI).

• the balloon is mounted on the tip of a very thin catheter. It is inserted through the obstruction using X-ray fluroscopy. Then it is inflated with dilute contrast material
• multiple inflations of the balloon using a pressure of several atmospheres will crack and squash the atheroma, and hence relieve the obstruction
• the technique is used for treatment of angina due to isolated, non-calcified, proximal plaques. Often the treatment is given where patients have a relatively short history of myocardial ischaemia
• PCI is superior to medical therapy for the management of symptoms in stable angina in patients with single vessel disease
• stents are implanted in nearly all patients undergoing PCI (94% in the Euro-Heart Survey 2006) because of several advantages over simple balloon dilatation:
  • a lower incidence of restenosis and consequently a reduced need for medical treatment and repeat procedures for recurrent angina
  • the achievement of a consistently larger vessel lumen with more predictable relief of myocardial ischaemia
  • the ability to treat complex lesions for which coronary bypass grafting would otherwise be required
  • a more stable immediate result and reduced risk of early (peri-procedural) abrupt closure of the treated artery

For patients with either stable or unstable angina, or acute myocardial infarction and where percutaneous coronary intervention is the clinically appropriate procedure, stents should be routinely used (1).

Notes:

• late percutaneous coronary intervention (PCI) of a totally occluded infarct-related artery (IRA) in stable patients is currently not recommended based on the lack of clear clinical benefits in randomized controlled trials
  • a meta-analysis examined the use of PCI in IRA in stable patients (3)
    • authors concluded that meta-analysis suggests that late revascularization of an occluded IRA may improve left ventricular systolic function and remodeling, supporting the "open artery hypothesis"
      • reason why these changes have not resulted in clinical benefits in large clinical trials is subject to debate
• bivalirudin in combination with aspirin and clopidogrel is recommended for the treatment of adults with ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention (4)

Reference:

• (1) NICE (May 2000). Coronary artery stents in the treatment of IHD.
• (2) British Heart Foundation Factfile (May 2008). Managing patients with coronary stents
• (3) Abbate A et al. Late percutaneous coronary intervention for the totally occluded infarct-related artery: a meta-analysis of the effects on cardiac function and remodeling. Catheter Cardiovasc Interv. 2008 May 1;71(6):772-81
• (4) NICE (July 2011). Bivalirudin