What is Percutaneous Coronary Intervention (PCI)?

What is Percutaneous Coronary Intervention (PCI)?

Percutaneous Coronary Intervention (PCI) is a non-surgical procedure used to treat narrowed or blocked coronary arteries through a catheter-based approach to improve blood flow to the heart muscle. 1

Definition and Evolution

PCI refers to a family of catheter-based techniques for treating coronary artery disease, including:

• Standard balloon angioplasty (originally called PTCA - Percutaneous Transluminal Coronary Angioplasty)
• Intracoronary stenting (now the dominant technique)
• Atheroablative technologies (atherectomy, thrombectomy, laser angioplasty) 2

The technique has evolved significantly since its inception:

• Initially limited to balloon angioplasty
• Now predominantly involves balloon dilation followed by coronary stenting
• Modern PCI includes drug-eluting stents that have markedly reduced restenosis rates 2

Procedural Details

The procedure involves:

1. Accessing the arterial system (typically via femoral or radial artery)
2. Advancing a catheter to the coronary arteries under X-ray guidance
3. Identifying stenoses through coronary angiography
4. Treating the narrowed segments using balloons, stents, or other devices
5. Administering adjunctive pharmacotherapy (antiplatelet and antithrombotic medications)

Clinical Indications

PCI is indicated in several clinical scenarios:

Stable Coronary Artery Disease

• Valuable initial mode of revascularization in patients with objective large ischemia
• Suitable for almost every lesion subset except chronic total occlusions that cannot be crossed 2

Acute Coronary Syndromes

• ST-Elevation Myocardial Infarction (STEMI):

  • Primary PCI is the treatment of choice when available with an experienced team
  • Should be performed with balloon inflation within 90 ± 30 minutes of admission 2
  • Superior to thrombolysis in preserving myocardium, especially 3-12 hours after symptom onset 2

• Non-ST-Elevation Acute Coronary Syndromes (NSTE-ACS):

  • Early angiography (≤48 hours) and PCI when needed shows clear benefit in high-risk groups 2
  • Routine stenting is recommended for predictability of results and immediate safety 2

Cardiogenic Shock

• Emergency PCI for complete revascularization may be life-saving
• Should be considered at an early stage 2

Institutional Requirements

For safe and effective PCI delivery:

• Minimal institutional performance of 200 interventions per year (ideally 400+)
• Interventional program director with >500 PCI procedures experience 1
• For primary PCI without on-site cardiac surgery: minimum of 36 primary PCI procedures per year
• Operators should perform ≥75 PCIs per year to maintain competency 2

Effectiveness and Outcomes

PCI offers several benefits:

• Improves quality of life by relieving angina in stable coronary disease
• Can be life-saving in extensive ischemia and acute coronary syndromes 3
• Achieves TIMI 3 flow (complete reperfusion) in 70-90% of cases 2
• Late follow-up angiography demonstrates 87% of infarct arteries remain patent 2

Limitations and Considerations

Important caveats to consider:

• PCI may not be optimal for all patients with coronary disease
• Some patients with high-risk features (like reduced left ventricular function) may have improved long-term survival with CABG 2
• Complex cases, particularly those involving left main or multivessel disease, benefit from multidisciplinary evaluation 1
• In diabetics with multi-vessel disease and patients with unprotected left main stenosis, CABG may be preferred over PCI 2

Technological Advances

Recent advances have improved PCI outcomes:

• Drug-eluting stents have significantly reduced restenosis rates
• Adjunctive pharmacotherapy (GP IIb/IIIa inhibitors, thienopyridines) has enhanced safety and durability
• Intravascular imaging technologies (IVUS, OCT) provide detailed plaque characterization and guide stent deployment
• Fractional Flow Reserve (FFR) improves decision-making about which lesions require intervention 1

PCI continues to evolve with ongoing development of next-generation stents and improved pharmacologic agents, solidifying its pivotal role in the management of coronary artery disease.