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Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Stenosis

Key Points Coronary angiography has limitations in assessing left main coronary artery (LMCA) disease and guiding treatment. The complementary use of coronary physiology and imaging modalities is helpful to improve outcomes following LMCA stenting. Long-term prognosis following ostial or shaft LMCA stenting is excellent. When treating the distal LMCA bifurcation, the interventionalist should understand the advantage and disadvantage of each stenting strategy. Whatever percutaneous coronary intervention…

Bifurcations and Branch Vessel Stenting

Key Points Always consider an ostial lesion as a possible bifurcation lesion, except in cases of aortoostial location. A 6-Fr guiding catheter is appropriate most of the time; when in doubt, use 7- or 8-Fr. Do not risk losing the side branch (SB); when in doubt, always protect it with a wire. If there are difficulties wiring the SB, consider dilating the main branch first. Provisional…

Interventions in Cardiogenic Shock

Key Points Cardiogenic shock (CS) remains the leading cause of death among patients hospitalized with acute myocardial infarction (AMI). Left ventricular (LV) dysfunction accounts for most CS in AMI patients. Early restoration of perfusion to the territory supplied by the infarct-related artery is of paramount importance in preventing CS and changing outcomes once it has developed. The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock…

Post-Percutaneous Coronary Intervention Hospitalization, Length of Stay, and Discharge Planning

Key Points Comprehensive post-percutaneous coronary intervention (PCI) discharge management is an integral aspect of postprocedure care and includes direct patient communication, monitoring for procedural or vascular complications, and clear discharge instructions with a specific follow-up plan. Medication reconciliation, especially regarding dual antiplatelet therapy (DAPT) post-PCI, is critical for aggressive secondary prevention and to prevent late complications. Evaluation of cardiac biomarkers post-PCI is controversial. Although it is…

Percutaneous Coronary Intervention in Acute ST-Segment Elevation Myocardial Infarction

Key Points Catheter-based primary percutaneous coronary intervention (PPCI) has become the mainstay of reperfusion therapy in patients with ST-elevation myocardial infarction (STEMI). PPCI is superior to thrombolytic therapy in reducing death, reinfarction, intracranial bleeding, reocclusion of the infarct-related artery, and myocardial ischemia in patients with STEMI irrespective of the patient’s risk or whether interhospital transfer for PCI is required. Regional systems of care coordinating hospitals and…

Intervention for Non–ST-Segment Elevation Acute Coronary Syndromes

Key Points All patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) need to undergo risk stratification at the time of diagnosis. Risk stratification provides prognostic value and helps guide the therapeutic decision-making process. Immediate angiography within 2 hours is recommended for NSTE-ACS patients who present with either hemodynamic instability or life-threatening arrhythmias or mechanical complications of myocardial infarction. Compared with ischemia-guided management, an early invasive strategy…

Elective Intervention for Stable Angina or Silent Ischemia

Key Points Chronic angina is a growing worldwide problem with significant economic and societal costs. By reducing the ischemic burden, percutaneous coronary revascularization provides important clinical benefit in patients with established obstructive coronary artery disease (CAD). The foremost effect is prompt symptom control and improved exercise tolerance. Direct evidence for improvement in survival or definitive reduction of major cardiovascular events is lacking in the broad population…

Drug-Eluting Balloons

Key Points Drug-coated balloon (DCB) catheters are the most advanced proven alternative to drug-eluting stents for local intravascular drug delivery. Preclinical data indicate effective inhibition of restenosis; however, there is no uniform class effect on drug-coated balloons. Randomized clinical trials have shown the efficacy and safety of these devices in the treatment of coronary in-stent restenosis (ISR) and treatment of de novo and nonstented restenotic lesions…

Bioresorbable Coronary Scaffolds

Key Points Bioresorbable scaffolds (BRS) have the potential to overcome the remaining limitations of new generation drug eluting stents (DES) by providing temporary vessel scaffolding and then disappearing. They are composed of either polymer or corrodible metal-based alloys and the most frequently used material in the current generation of BRS is poly(L-lactic) acid (PLLA) followed by magnesium. As of May 2017, five BRS—Absorb, DESolve, ART Pure,…

Coronary Stenting

Key Points Bare-metal stents (BMS) overcome many of the drawbacks of balloon angioplasty but are limited by restenosis, which develops in 20% to 40% of cases. Drug-eluting stents (DES)—which consist of a metallic stent coated with a drug carrier vehicle (usually a polymer) that controls the dose and timing of the elution of an antiproliferative agent—have been shown to significantly reduce in-stent late loss, resulting in…

Coronary Stenting : Practical Considerations, Equipment Selection, Tips and Caveats

Key Points Access selection is a key decision that should encompass patient comfort, but ultimately be driven by the complexity of the case and operator confidence. Proper guide selection to ensure good support is key to any percutaneous coronary intervention. A lack of guide support can be overcome by the use of guide extensions and a variable guide technique. Coronary wire choice should encompass the ability…

Other Adjunctive Drugs for Coronary Intervention: Beta-Blockers, Calcium-Channel Blockers, and Angiotensin-Converting Enzyme Inhibitors

Key Points β-Blockers provide long-term mortality reduction after myocardial infarction (MI). Although β-blockers are beneficial, they should be used carefully immediately after MI to avoid cardiogenic shock in susceptible patients. Calcium-channel blockers are reasonable alternatives to β-blockers after MI in the few patients with strong contraindications to β-blockers. Angiotensin-converting enzyme (ACE) inhibitors reduce mortality in patients after MI, especially in those with left ventricular (LV) dysfunction.…

Thrombolytic Intervention

Key Points Thrombolytic therapy remains the preferred reperfusion strategy in patients with ST-elevation myocardial infarction (STEMI) who present within 12 hours of symptom onset when timely primary percutaneous coronary intervention (PCI) is not available and no contraindications to thrombolysis are present. Adjunctive antiplatelet and antithrombotic therapies are critical to the maintenance of epicardial vessel patency and to the reduction of downstream microvascular obstruction in patients treated…

Anticoagulation in Percutaneous Coronary Intervention

Key Points Platelets and coagulation play a synergistic role in the generation of thrombus. Improved antithrombin approaches reduce the dependence on antiplatelet therapy for achieving suppression of ischemic events. Although the impact of ischemic events on late mortality is well appreciated, a robust link between bleeding events and late mortality is evident. These factors bear careful consideration when weighing efficacy and safety considerations among antithrombotic therapies.…

Platelet Inhibitor Agents

Key Points Dual-antiplatelet therapy (DAPT) with aspirin and a P2Y 12 receptor inhibitor is the cornerstone of therapy after percutaneous coronary intervention (PCI) with stents. The thienopyridines—ticlopidine, clopidogrel, and prasugrel—are P2Y 12 inhibitors that are prodrugs and therefore require conversion into an active metabolite to exert their antiplatelet effect. This active metabolite irreversibly binds and antagonizes the P2Y 12 receptor for the lifespan of the platelet.…

Sex and Ethnicity Issues in Interventional Cardiology

Key Points Women who present for percutaneous coronary intervention (PCI) are generally older and have more comorbidities compared with men. Women and men have comparable short- and long-term outcomes with bare-metal stents (BMSs) and drug-eluting stents (DESs), including similar mortality rates after PCI. Adjunctive PCI devices such as directional coronary atherectomy and excimer laser atherectomy are associated with higher complication rates in women. Women have higher…

Coronary and Valvular Intervention Prior to Noncardiac Surgery

Key Points Perioperative myocardial infarction typically occurs in the first 48 to 72 hours following noncardiac surgery (NCS) and, even if clinically silent, is associated with substantial early and late mortality. The initiation of β-blocker and/or aspirin therapy prior to NCS for patients not already taking these medications is associated with an increase in adverse perioperative events and is not recommended. The indications for performing coronary…

Radiation Safety During Cardiovascular Procedures

Key Points Interventional cardiologists who use fluoroscopy should be familiar with radiation risks and should know how to manage radiation appropriately. Incidents of patient skin injury following fluoroscopy-guided interventional procedures have been reported. Many reported skin effects resulting from fluoroscopic procedures were inadvertent, because the physician was unaware of the radiation dose and consequences. Interventional cardiologists must receive training in selection of appropriate fluoroscopic equipment configuration…

Contrast-Induced Acute Kidney Injury and the Role of Chronic Kidney Disease in Percutaneous Coronary Intervention

Key Points Although the advent of new-generation contrast agents has resulted in a decreased incidence of contrast-induced acute kidney injury (CI-AKI), it remains a concern especially in patients undergoing cardiac catheterization. Chronic kidney disease (CKD) as one of the most important predictors of CI-AKI is rapidly increasing worldwide. Risk factors for AKI in general are common and overlap with risk factors for CI-AKI. Differentiating true CI-AKI…

Intracoronary Pressure and Flow Measurements

Key Points Angiography alone is often insufficient to assess intermediate and, at times, severe stenoses. Although adjunctive stress testing has limitations, fractional flow reserve (FFR) provides an accurate detector of lesion specific myocardial ischemia. Deferring revascularization of a coronary stenosis with a non-“ischemic” FFR has a favorable long-term outcome. Percutaneous coronary intervention (PCI) guided by FFR is clinically and economically superior to angiography-guided PCI in patients…