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Percutaneous coronary intervention
Percutaneous coronary intervention (PCI), commonly known as coronary angioplasty or simply angioplasty, is a therapeutic procedure to treat the stenotic (narrowed) coronary arteries of the heart found in coronary heart disease. These stenotic segments are due to the build up of cholesterol-laden plaques that form due to atherosclerosis. PCI is usually performed by an invasive cardiologist.
Percutaneous coronary intervention can be performed to reduce or eliminate the symptoms of coronary artery disease, including angina (chest pain), dyspnea (shortness of breath) on exertion, and congestive heart failure. PCI is also used to abort an acute myocardial infarction, and in some specific cases it may reduce mortality.
Additional recommended knowledge
Coronary angioplasty, also known as "percutaneous transluminal coronary angioplasty" (PTCA), was first developed in 1977 by Andreas Gruentzig. The procedure was quickly adopted by numerous cardiologists, and by the mid-1980s, many leading medical centers throughout the world were adopting the procedure as a treatment for coronary artery disease (CAD).
Angioplasty is sometimes eponymously referred to as Dottering, after Dr Charles Theodore Dotter, who, together with Dr Melvin P. Judkins, first described angioplasty in 1964. As the range of procedures performed upon lumens of coronary arteries has widened, the name of the procedure has changed to percutaneous coronary intervention (PCI).
The term balloon angioplasty is commonly used to describe percutaneous coronary intervention, which describes the inflation of a balloon within the coronary artery to crush the plaque into the walls of the artery. While balloon angioplasty is still done as a part of nearly all percutaneous coronary interventions, it is rarely the only procedure performed.
Other procedures that are done during a percutaneous coronary intervention include:
Sometimes a small mesh tube, or "stent", is introduced into the blood vessel or artery to prop it open using percutaneous methods. Angioplasty with stenting is a viable alternative to heart surgery for some forms of non-severe coronary artery disease. It has consistently been shown to reduce symptoms due to coronary artery disease and to reduce cardiac ischemia, but has not been shown in large trials to reduce mortality due to coronary artery disease, except in patients being treated for a heart attack acutely (also called primary angioplasty). There is a small but definite reduction of mortality with this form of treatment compared with medical therapy, which usually consists of the administration of thrombolytic ("clot busting") medication.
The angioplasty procedure usually consists of most of the following steps and is performed by physicians, physician assistants, nurses, radiological technologists and cardiac invasive specialist; all whom have extensive and specialized training in these types of procedures.
Traditional ("bare metal") coronary stents provide a mechanical framework that holds the artery wall open, preventing stenosis, or narrowing, of coronary arteries. PTCA with stenting has been shown to be superior to angioplasty alone in patient outcome by keeping arteries patent for a longer period of time.
Newer drug-eluting stents (DES) are traditional stents that are coated with drugs, which, when placed in the artery, release certain drugs over time. It has been shown that these types of stents help prevent restenosis of the artery through several different physiological mechanisms, which rely upon the suppression of tissue growth at the stent site and local modulation of the body's inflammatory and immune responses. Three drugs, sirolimus, everolimus and paclitaxel, have been demonstrated safety and efficacy in this application in controlled clinical trials by stent device manufacturers. However, in 2006 three broad European trials seem to indicate that drug-eluting stents may be susceptible to an event known as "late stent thrombosis", where the blood-clotting inside the stent can occur one or more years post-stent. While this event is rare, it is extremely dangerous and is fatal in about one-third of cases when the thrombosis occurs. 
Risks of angioplasty are uncommon, and the procedure is widely practiced. Coronary angioplasty is usually performed by an interventional cardiologist, a medical doctor with special training in the treatment of the heart using invasive catheter-based procedures.
Angioplasty has become considerably safer over the years and is now commonly performed. Although it is associated with some risks these are considerably less than for open-heart bypass surgery with its resulting post-operative pain. However the likelihood of recurrence of angina, and requirement for repeated procedures has been higher with angioplasty. The latest trial (ARTS II) has suggested that PCI with DES may be superior, at least in the short term.
Some chest discomfort occasionally may be experienced and it is for this reason that the patient is awake during minimally invasive angioplasty; the reporting of any symptom allows the cardiologist to take necessary immediate action. Bleeding from the insertion point in the groin is common, in part due to the use of anti-platelet clotting drugs. Some bruising is therefore to be expected, but occasionally a hematoma may form. This may delay hospital discharge as flow from the artery into the hematoma may continue (pseudoaneurysm) which requires repair. Infection at the skin puncture site is rare and dissection (tearing) of the access blood vessel is uncommon. Allergic reaction to the contrast dye used is possible, but has been reduced with the newer agents. Deterioration of kidney function can occur in patients with pre-existing kidney disease, but kidney failure requiring dialysis is rare. Vascular access complications are less common and less serious when the procedure is performed via the radial artery.
In the long term, the most common risk is of the stent restenosis, as discussed above. This has been reduced considerably with the use of newer stents coated with certain medicines (drug-eluting stents). The most serious risk is the rare provocation (3%) of a heart attack during or shortly after the procedure; this may require emergency open cardiac surgery. Angioplasty carried out shortly after a myocardial infarction has a risk of causing a stroke of 1 in 1000, which is less than the 1 in 100 risk encountered by those receiving thrombolytic drug therapy.
The overall risks of death with angioplasty is approximately 1%, but the underlying severity of the heart disease, fitness of the patient and presence of other illness affect each individual’s risk. Hence for those with relatively minor heart disease, preserved good cardiac function, reasonable level of fitness and absence of other illnesses, the risk will be considerably less.
When failures of PTCA occur, they are often treated using coronary artery bypass surgery (CABG).
|This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Percutaneous_coronary_intervention". A list of authors is available in Wikipedia.|