Percutaneous coronary intervention (PCI) is a non-surgical procedure that involves inserting a small stent (a tube) into narrowed blood vessels in the heart to help maintain its patency. The narrowing is often caused by plaque buildup due to a condition called atherosclerosis.
Percutaneous coronary intervention is preferred over coronary artery bypass graft (CABG) if:
- There are no signs of disease in the main artery supplying the heart, also called the left anterior descending artery (LAD).
- When CABG is no longer a viable option, stents are the best option.
Coronary stents versus bypass surgery
- Despite their extensive usage in the treatment of acute heart attacks and restricted arteries, stents can induce inflammation and scar tissue formation, causing channels to constrict again.
- The percutaneous coronary intervention (PCI) procedure to install a stent needs a shorter hospital stay than standard open-heart bypass surgery, has faster recovery rates, and is less likely to induce strokes.
- Though stents are less dangerous for patients in the first month or two following the treatment, they become more dangerous in the years that follow, with a higher risk of heart attack and death.
- Newer stents are designed to be more compatible with living tissue and less prone to induce clots, inflammation, and tissue development.
- However, long-term comparison data from randomized studies of CABG vs. PCI using drug-eluting stents (DES) are limited.
Recommendations of primary PCI
- Primary PCI is only suggested when symptoms have been present for 12 to 24 hours (delayed presentation), and there is severe congestive heart failure, hemodynamic, electrical instability, or persistent angina (chest pain).
- When symptoms have been present for more than 12 hours and the patient is asymptomatic, primary PCI is not suggested.
If specific conditions are met, PCI may be appropriate for patients with stable coronary artery disease. Having coronary stenosis more than 50 percent or angina symptoms are refractory to medical treatment.
However, whether to do a PCI over a CABG or a CABG over a PCI is always varies with individuals. A doctor always weighs and discusses the advantages and cons with their patients to reach a shared decision.
What is CAD?
Coronary artery disease (CAD) occurs when the arteries that supply blood to the heart narrow or become blocked by a buildup of fatty deposits called plaque. As a result, the arteries struggle to supply blood to the heart.
Some of the symptoms of CAD are:
- Chest pain (angina)
- Shortness of breath
- Heaviness in the chest
- Pain in the jaw or down the arms
- Heavy sweating
There are several risk factors for coronary artery disease, such as:
- Family history of heart disease
- Poor eating habits and stressful life
However, most of the risk factors can be controlled. These factors, when successfully addressed, can reduce the risk of future heart disease.
- Smoking causes the release of chemicals in the body, causing a pro-inflammatory state. This raises the risk of blood clots.
- Obesity or excess body fat, particularly around the waist, can contribute to high blood pressure and cholesterol.
- CAD may be exacerbated by a lack of physical activity or an inactive lifestyle.
- High blood pressure strains the heart and directly damages blood vessels, making plaque formation easier. Diabetes causes excess sugar to accumulate in blood vessels, causing nerve damage.
- High levels of cholesterol in the blood can cause atherosclerosis or the formation of thick, fatty plaque that clogs arteries.
If the doctor suspects that a person has CAD, the person would likely be asked to take a physical exam to check their heart and see how well it is working.
Some of the tests used to diagnose CAD include:
How is PCI performed?
A percutaneous coronary intervention (PCI) or angioplasty is performed to enhance blood flow to the heart during or after a heart attack or to treat symptoms of coronary artery disease. PCI is performed as part of a cardiac catheterization.
- Cardiac catheterization is a technique in which a catheter is put into a major blood artery in the arm or groin to the heart.
- This allows the doctor to see inside the heart and assess the level of damage to the arteries.
The technique for cardiac catheterization with PCI consists of the following steps:
- An intravenous catheter is inserted into the arm to administer a sedative. During the catheterization, the patient will be awake but relaxed.
- Before inserting the cardiac catheter into the blood vessel, the groin or arm is numbed. This catheter travels to the heart via the blood vessels.
- An X-ray is used to view an image of the heart on a monitor after a dye is injected into the catheter.
- The dye injected into the catheter allows the doctor to see if there are any blockages in the arteries of the heart.
- After locating the blockage, a second catheter is inserted and guided to the heart. A balloon is attached to the tip of this catheter.
- To widen the blocked artery and increase blood flow, the balloon is inflated.
- After the balloon is inflated, a stent is usually placed to keep the artery open.
- A stent is a cylinder-shaped metal mesh tube that expands the artery walls and allows blood to flow through them.
- The catheters are removed from the blood vessel once the PCI and stent procedures are completed.
- To prevent bleeding, a pressure bandage is applied to the insertion site, and movement is restricted for several hours.
Some PCIs can be performed as an outpatient procedure, allowing the patient to go home after a few hours of observation. Other PCIs necessitate the patient spending the night in the hospital.
A couple of types of stents can be placed during a PCI, such as:
- Bare metal stent (BMS): Usually made of stainless steel.
- Drug-eluting stent (DES): The metal stent is coated with growth inhibitors, which slow down smooth muscle reproduction, reducing the likelihood of another blockage.
A DES is thought to be superior to a BMS, but certain situations preclude its use. Antiplatelet therapy lasts longer with a DES than with a BMS to prevent stent thrombosis (a blood clot in the artery where the stent is). Some people cannot tolerate antiplatelet therapy for long periods, making them candidates for a BMS rather than DES.
Risks of the procedure
- Bruising at the site of catheter insertion (usually the groin or the wrist)
- A blood clot or damage to the blood vessel at the site of insertion
- A blood clot within a vessel that was treated with PCI or a stent
- Infection at the site of catheter insertion
- Arrhythmias or cardiac dysrhythmias (abnormal heart rhythms)
- Acute myocardial infarction
- Pain or discomfort in the chest
- Coronary artery rupture necessitating open-heart surgery
- Pregnancy, dye allergy, anesthesia, and other specific medical conditions pose a risk
- Other major complications, such as death, are uncommon (0.2 percent chances and higher chances in high-risk cases)
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What is the recovery period after percutaneous coronary intervention?
After a percutaneous coronary intervention (PCI), patients usually recover quickly. Following the procedure, they are monitored and observed.
- Any catheter equipment still in the skin and artery is removed 4 to 12 hours later, and pressure is applied for about 20 minutes by hand, clamps, or "sandbags" to prevent bleeding into the catheter insertion site.
- Alternatively, some patients may have the artery where the catheter was placed sutured.
- Patients are administered antiplatelet agents that thin the blood. Most patients will be on antiplatelet medication indefinitely.
- After a percutaneous coronary intervention, patients are usually discharged within 24 hours and advised not to engage in any strenuous activity or lift anything heavier than 20 pounds for one to two weeks.
- Some patients may be referred to a rehabilitation center but the majority are not and can return to work (if the job is not physically demanding) in three days after undergoing percutaneous coronary intervention.
What are the long-term results of percutaneous coronary intervention?
Long-term results have improved as percutaneous coronary intervention (PCI) techniques have progressed from balloon to balloon plus stent to balloon plus drug-eluting stent, with recurrent narrowing or blockage occurring in less than 10 percent of patients.
Most stented coronary arteries remain open in the stented area for many years if there is no evidence of recurrence of narrowing or blockage (for example, a negative stress test) after about 12 months.
Unfortunately, additional stents may be required in the future to treat other areas of the artery. Patients who do not take their antiplatelet medication as prescribed and continue to live a lifestyle that promotes coronary artery cholesterol accumulation and arterial narrowing are more likely to have stent failure or additional arterial narrowing or blockage.
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Spadaccio C, Benedetto U. Coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) in the treatment of multivessel coronary disease: quo vadis? -a review of the evidences on coronary artery disease. Ann Cardiothorac Surg. 2018;7(4):506-515. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082779/
Rihal CS, Raco DL, Gersh BJ, Yusuf S. Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina: review of the evidence and methodological considerations. Circulation. 2003 Nov 18;108(20):2439-45. https://www.ahajournals.org/doi/10.1161/01.cir.0000094405.21583.7c
Serruys P, Garg S. Percutaneous coronary interventions for all patients with complex coronary artery disease: triple vessel disease or left main coronary artery disease. Yes? No? Don't know? Rev Esp Cardiol. 2009 Jul;62(7):719-25. https://www.revespcardiol.org/es-percutaneous-coronary-interventions-for-all-articulo-13140253
The University of Texas Southwestern Medical Center. Percutaneous Coronary Intervention. https://utswmed.org/conditions-treatments/percutaneous-coronary-intervention-pci/
Cardiology Advisor. Selecting PCI, CABG or medical therapy: Current Recommendations. https://www.thecardiologyadvisor.com/home/decision-support-in-medicine/cardiology/selecting-pci-cabg-or-medical-therapy-current-recommendations/#
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