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Distal protection 

Distal protection
Chapter:
Distal protection
Author(s):

William J. van Gaal

and Adrian P. Banning

DOI:
10.1093/med/9780199569083.003.037
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date: 27 February 2020

Percutaneous coronary intervention (PCI) aims to restore normal epicardial flow and improve microvascular perfusion to the vascular bed beyond the obstructive coronary stenosis. In the setting of elective PCI, the goal is to achieve this without injury to the distal myocardium, whilst in acute coronary syndromes, namely acute ST elevation myocardial infarction (STEMI), the goal is restore epicardial patency and microvascular perfusion as quickly as possible to limit the extent of irreversibly injured (necrotic) myocardium. The pathophysiology of distal injury in these clinical scenarios differs, and thus protection of the myocardium in the elective and acute setting requires different approaches.

The concept of distal protection was initially trialled during vein graft PCI. Vein grafts are large capacious conduits with large volumes of plaque. The concept that a basket placed downstream on the wire might catch plaque liberated during balloon expansion was the subject of a number of landmark studies proving in concept that this approach might be beneficial in these specific patients. A number of different devices have evolved and their use is considered routine in most centres when vein grafts are being treated.

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