Planning a Percutaneous Coronary Intervention (PCI) Case: A Systematic Approach
PCI planning requires a systematic approach that includes careful assessment of coronary anatomy, lesion characteristics, and appropriate selection of equipment based on established guidelines. The following steps will guide you through planning and executing a successful PCI procedure.
Pre-Procedure Planning
1. Patient and Lesion Assessment
- Review coronary angiography to determine:
- Target vessel and lesion location
- Lesion characteristics (length, calcification, tortuosity, bifurcation)
- Reference vessel diameter
- Presence of thrombus
- Collateral circulation
- Use IVUS (Intravascular Ultrasound) when appropriate for:
2. Access Site Selection
- Radial access is recommended as the standard approach unless there are overriding procedural considerations 1
- Consider femoral access for complex cases requiring larger guide catheters or when radial access is not feasible
Procedural Equipment Selection
1. Guide Catheter Selection
- Choose based on:
- Target vessel (e.g., JL for left system, JR for right coronary artery)
- Required support (e.g., EBU, XB, or AL for increased support)
- Size: 6F is standard for most cases, 7-8F for complex procedures requiring larger equipment
2. Guidewire Selection
- Initial wire choice:
- Workhorse wire (0.014" floppy-tipped wire) for straightforward lesions
- Examples: BMW, Runthrough, Prowater
- Specialized wires based on lesion characteristics:
- Tortuous vessels: Hydrophilic coated wires (e.g., Whisper, Fielder)
- Calcified lesions: Stiffer wires with good torque control (e.g., Grand Slam, Iron Man)
- Chronic total occlusions (CTOs): Specialized CTO wires with tapered tips (e.g., Fielder XT, Confianza Pro)
- Consider J-CTO score for CTO cases to determine approach and likelihood of success 2
3. Balloon Selection
- Pre-dilation balloon:
- Size: Generally 0.5mm smaller than reference vessel diameter
- Length: Typically 15-20mm to cover the lesion
- Specialized balloons for specific scenarios:
- Calcified lesions: Scoring or cutting balloons 1
- Non-compliant balloons for resistant lesions
- Post-dilation balloon (if needed):
- Non-compliant balloon sized 1:1 with reference vessel diameter
- Length shorter than stent length to avoid edge dissection
4. Stent Selection
- Drug-eluting stents (DES) are recommended over bare-metal stents (BMS) for any PCI regardless of:
- Clinical presentation
- Lesion type
- Planned duration of DAPT 1
- Size: Match to reference vessel diameter (typically 1:1 ratio)
- Length: Cover entire lesion with 2-3mm margins on each end
Antithrombotic Management
1. Pre-Procedure Antiplatelet Therapy
- For elective PCI:
- For ACS patients:
- Consider more potent P2Y12 inhibitors (prasugrel or ticagrelor) 1
2. Procedural Anticoagulation
- Unfractionated heparin (UFH) is indicated as standard anticoagulant:
- Dosage: 70-100 U/kg 1
- Monitor ACT (activated clotting time) with target 250-300 seconds for procedures without GP IIb/IIIa inhibitors
- Bivalirudin may be considered as an alternative to reduce bleeding risk 3
- Fondaparinux should not be used as the sole anticoagulant for PCI 1
Procedural Approach
1. Lesion Preparation
- Cross lesion with appropriate guidewire
- Pre-dilate lesion if:
- Severe stenosis
- Calcified lesion
- CTO after recanalization
- Consider specialized techniques for complex lesions:
2. Stent Deployment
- Position stent precisely to cover entire lesion
- Deploy at appropriate pressure (usually 10-14 atm)
- Consider IVUS to assess stent apposition and expansion 1
3. Post-Stent Optimization
- Post-dilate with non-compliant balloon if:
- Residual stenosis
- Suboptimal stent expansion
- IVUS shows incomplete stent apposition
- Final angiography in multiple views to confirm:
- Adequate stent expansion
- No edge dissection
- TIMI 3 flow
Special Considerations
1. Bifurcation Lesions
- Stent implantation in the main vessel only, followed by provisional balloon angioplasty with or without stenting of the side branch, is recommended 1
- Consider two-stent techniques (T-stenting, Culotte, DK-crush) for large side branches with significant disease
2. Chronic Total Occlusions
- Requires specialized equipment and techniques
- Consider antegrade vs. retrograde approach based on lesion characteristics
- Use specialized CTO wires and microcatheters for support
3. Calcified Lesions
- Consider IVUS to establish presence and distribution of calcium 1
- Use rotational atherectomy for heavily calcified lesions that cannot be crossed or dilated with conventional balloon angioplasty 1
4. Cardiogenic Shock
- Consider hemodynamic support devices for high-risk patients 1
- Primary PCI should be performed for patients with cardiogenic shock due to STEMI or NSTE-ACS 1
Post-Procedure Management
1. Antiplatelet Therapy
- DAPT (Dual Antiplatelet Therapy):
2. Follow-up
- Monitor for complications:
Common Pitfalls to Avoid
- Inadequate lesion preparation - Particularly important for calcified or complex lesions
- Inappropriate stent sizing - Undersized stents increase restenosis risk; oversized stents risk dissection or perforation
- Geographic miss - Failure to cover the entire lesion with the stent
- Edge dissections - Can lead to acute vessel closure if not recognized and treated
- Premature discontinuation of DAPT - Can lead to catastrophic stent thrombosis 5
- Contrast nephropathy - Minimize contrast volume and ensure adequate hydration 4
By following this systematic approach to PCI planning and execution, you can optimize procedural success and minimize complications, ultimately improving patient outcomes.