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Percutaneous interventional cardiac procedures 

Percutaneous interventional cardiac procedures

Chapter:
Percutaneous interventional cardiac procedures
Author(s):

Edward D. Folland

DOI:
10.1093/med/9780199204854.003.161306_update_002

Update:

Transcutaneous aortic valve implantation indications and outcomes. Pressure wire measurement of clow reserve to guide coronary intervention. Use of intravascular ultrasound and optical coherence tomography. Non cardiac surgery following coronary intervention. This chapter now includes content from retired Chapter 16.13.8.

Updated on 29 Oct 2015. The previous version of this content can be found here.
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date: 25 March 2017

Percutaneous coronary intervention (PCI) is the term applied to a variety of percutaneous, catheter-based procedures that accomplish revascularization by angioplasty (enlargement of a vessel lumen by modification of plaque structure), stenting (deployment of an internal armature or stent), atherectomy (removal or ablation of plaque), or thrombectomy (removal of thrombus).

The most common single indication for PCI is acute coronary syndrome. Randomized trials have shown that direct intervention for ST-elevation myocardial infarction (STEMI) is superior to initial thrombolytic therapy when performed in appropriate centres, and it can be used as a salvage procedure after failed thrombolytic therapy.

Balloon angioplasty is the traditional, basic technique of coronary intervention, but it is now uncommonly employed as a stand-alone treatment and finds its chief application in deployment of balloon-expandable stents, which have become the intervention of choice in about 90% of cases undergoing PCI. A variety of percutaneous techniques can be used to remove atheroma or thrombus from coronary arteries as a prelude to angioplasty/stenting.

There are two main types of coronary stent ‘bare metal’ and ‘drug eluting’. The latter contain a drug (e.g. sirolimus, paclitaxol, etc.) that inhibits smooth muscle proliferation and thereby considerably reduces the risk of restenosis, which is the most common complication of stenting. Restenosis typically presents as exertional angina at 1 to 6 months following intervention: if it is not present at 6 months, it is unlikely to occur.

Percutaneous techniques can also be used to treat some forms of valvular disease and close cardiac defects in (highly) selected cases. Balloon valvuloplasty is the preferred treatment, when feasible, for patients with stenosis of mitral and pulmonic valves. Transcatheter aortic valve implantation has proven safe and effective as an alternative to surgical valve replacement in patients for whom surgical risk is very high or prohibitive. Atrial septal defect can be successfully closed with a clamshell device in many cases. Patent foramen ovale likewise can be closed with a percutaneously delivered device, although the indications for this procedure remain controversial. Percutaneous clipping of mitral valve leaflets in some patients with mitral regurgitation has been accomplished with safety equivalent to that of surgical treatment. Nevertheless, the benefit of this procedure is less than that of surgery.

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