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percutaneous transluminal coronary angioplasty (PTCA)

An invasive procedure to enlarge the lumen of a narrowed coronary artery by balloon compression. The angioplasty catheter is inserted into a coronary artery, & the cylindrical balloon is inflated at the site of an obstructing atheroma. Indications: 1) primary therapy for unstable angina with ST segment elevation* (see CAPITAL AMI study, STEMI) [17] 2) rescue therapy following failed thrombolysis a) persistent hemodynamic instability or arrhythmia b) 60-90 minutes after initiation of thrombolytic therapy 3) patient not eligible for thrombolytic therapy 4) myocardial infarction complicated by shock or CHF [14] 5) previous coronary artery bypass graft surgery 6) failure of medical management following initial stabilization 7) elective revascularization for coronary artery disease a) impaired left ventricular function 1] 2 or more vessels with > 50% stenosis - CABG preferred for multivessel disease with reduced LV ejection fraction [2] 2] viable left ventricular myocardium with abnormal wall motion b) normal left ventricular function with left main, 3-vessel or severe 2-vessel disease c) proximal left anterior descending artery disease (common clinical practice) 8) CABG is indicated for patients with diabetes mellitus who would otherwise be eligible for PTCA (better 5 year survival, 80% vs 65%) * may be better than thrombolysis for primary therapy [9] see 'PTCA vs thrombolysis for acute MI Contraindications: 1) elective PTCA for one vessel disease does not: a) reduce future risk of myocardial infarction b) improve resting left ventricular function c) increase survival 2) routine thrombectomy with PCI of no benefit (see thrombectomy) 3) late PCI to restore perfusion of infarcted myocardium of no benefit. [18] 4) preventive PCI in stable coronary disease of no benefit [19] 5) PCI for stable occluded coronary artery disease of little to no benefit [23] 6) late PCI for totally occluded coronary artery after myocardial infarction of no benefit [25] 7) PCI no better than medical therapy for stable coronary artery disease with proven myocardial ischemia [42] Procedure: - loading dose of clopidogrel 600 mg, followed by 150 mg/day for 6 days, then 75 mg/day - add aspirin 81 mg QD if coronary stenting - IV nitroglycerin for management of angina. - eptifibatide (Integrilin) for 12 hours after PTCA - coronary stenting may reduce the rate of restenosis [7] - treatment with abciximab with PTCA & coronary stenting may further reduce the rate of restenosis (10% at 6 months [7]) - facilitated PCI with reteplase plus abciximab or abciximab alone started early before PCI did improve outcomes, compared with primary PCI in STEMI patients [21] - intracoronary abciximab (0.25 mg/kg), delivered into the thrombus region with an infusion catheter [32] - manual aspiration thrombectomy with the Export catheter in patients with as large thrombus [32] - bivalirudin anticoagulation [32] Laboratory: - reperfusion is associated with higher peak serum CK-MB than persistent occlusion - platelet-function testing may be clinically relevant for a small proportion of patients [40] - high platelet reactivity confers risk of stent thrombosis Complications: 1) contrast nephropathy [12] 2) 30-45% restenosis within 6 months (20% in [7]) 3) patients with atrial fibrillation requiring warfarin plus clopidogrel plus aspirin at high risk of hemorrhage [36] 4) pseudoaneurysm or arteriovenous fistula at the site of catheter insertion [2,39] - duplex ultrasound to distinguish 5) stent thrombosis may occur in patients with high platelet reactivity [40] 6) accelerated idioventricular rhythm (ventricular tachycardia) is common following coronary reperfusion & does not require intervention when it occurs within the 1st 24 hours [2] Management: - PCI should be performed ASAP (as soon as possible) [27] - PCI should be performed within 90 minutes of medical contact - symptom onset to procedure time more important than door to procedure time (door to balloon time) [35] - PCI within 2 hours of symptom onset leads to better outcomes [35] - revascularization of non-infarct-related arteries in STEMI results in improved outcomes [41] - antiplatelet therapy - clopidogrel 600 mg prior to procedure or cangrelor 30 ug/kg bolus & 4 ug/kg infusion followed by 600 mg of clopidogrel at termination of infusion [37] - continue aspirin 81 mg PO QD + clopidogrel 75 mg daily PO QD [38] - combination B vitamins for 6 months - folate 1 mg, vitamin B12 400 ug, vitamin B6 10 mg PO QD - reduces serum homocysteine - reduced combined endpoint: myocardial infarction, death, restenosis (revascularization) {15% vs 23%} [8] - in other settings, the combination of folate, vitamin B6, & vitamin B12 have not been foun to reduce cardiovascular mortality - intraluminal radiation, beta-radiation (18 Gy) or gamma-radiation may also reduce rate of restenosis, including those with restenosis after stenting [6] - same day discharge after PTCA appears safe [29] - cardiac stress testing (stress echocardiography) after PCI may be appropriate [33] - routine electrocardiogram &/or cardiac stress testing in asymptomatic patients after successful PCI not indicated [2] Notes: - angioplasty would appear superior to streptokinase thrombolysis in the treatment of myocardial infarction, but requires expertise not yet available at many hospitals [4] - elective PTCA for multivessel disease has a slightly higher mortality than CABG [11] - at 1 year (5% vs 4%) - at 5 years (16% vs 14%) - CABG is superior to PCI for a) severe coronary artery disease [24]; see Syntax trial b) patients with diabetes mellitus [26] c) patients > 65 years of age [26] d) left main coronary artery disease e) multivessel coronary artery disease with involvement of left anterior descending coronary artery (LAD) & reduced LV ejection fraction [2] - facilitated percutaneous intervention is the use of pharmaceutical agents before a planned intervention a) mixed results b) pretreatment with clopidogrel decreased combined incidence of sudden death, myocardial infarction & stroke associated with PTCA in patients with STEMI. (4% vs 6%) [15] c) offered no benefit, outcomes may be worse [16] d) would be to become standard of care [37] - combination of pretreatment with clopidogrel + treatment with abciximab + heparin (during or after procedure) may be of benefit in patient with non-STEMI (see ISAR-REACT 2 trial) - prasugrel in combination with aspirin may be an option for patients with a) stent thrombosis during clopidogrel treatment b) diabetes mellitus (NGC, NICE) - percutaneous coronary intervention at hospitals without on-site cardiac surgery are noninferior to those at hospitals with on-site surgery [31] - outcomes independent of procedure appropriateness [34]

Related

Bypass Angioplasty Revascularization Investivation (BARI) cardiac catheterization coronary artery bypass grafting (CABG) coronary stent/coronary stenting ISAR-REACT 2 trial Syntax trial TIMI study

Specific

perfusion balloon angioplasty

General

percutaneous coronary intervention (PCI) angioplasty; balloon angioplasty coronary artery revascularization

References

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