Can percutaneous coronary intervention (PCI) be performed on the right posterior descending artery (RPDA)?

Can PCI Be Performed on the Right Posterior Descending Artery (RPDA)?

Yes, PCI can absolutely be performed on the right posterior descending artery (RPDA) when there is a significant stenosis (>70% diameter) causing ischemia or unacceptable angina despite medical therapy. 1

Technical Feasibility

The RPDA is a standard target vessel for percutaneous coronary intervention. The major guidelines from the ACC/AHA/SCAI do not exclude any specific coronary artery from PCI based on anatomic location alone. 1 The decision to intervene depends on:

• Stenosis severity: The lesion must be hemodynamically significant (>70% diameter stenosis for non-left main vessels, or >50% for left main disease) 1
• Evidence of ischemia: Objective documentation of ischemia on noninvasive testing or fractional flow reserve is required for stable patients 1, 2
• Clinical presentation: Unacceptable angina despite guideline-directed medical therapy, or acute coronary syndrome presentation 1

When PCI Should Be Performed on the RPDA

Class I Indications (Should Be Done)

• Acute coronary syndromes: PCI is beneficial for RPDA lesions in patients with STEMI or UA/NSTEMI when the RPDA is the culprit vessel 1
• Symptomatic relief: PCI is beneficial when there is ≥70% stenosis in the RPDA causing unacceptable angina despite optimal medical therapy 1
• Survivors of sudden cardiac death: When the RPDA has significant stenosis (>70%) and is presumed to be the ischemia-mediating vessel 1

Class IIa Indications (Reasonable to Perform)

• Previous CABG patients: PCI is reasonable for RPDA stenosis in patients with prior bypass surgery who have ischemia-related symptoms and are not candidates for reoperation 1
• When medical therapy cannot be implemented: Due to medication contraindications, adverse effects, or patient preferences 1

Critical Contraindications for RPDA PCI

Do not perform PCI on the RPDA in the following scenarios:

• No objective ischemia: Stable patients without documented ischemia on noninvasive testing, regardless of angiographic appearance 2, 1
• Insignificant stenosis: Lesions <50% diameter stenosis do not cause hemodynamically significant ischemia 2, 1
• Small myocardial territory at risk: When only a minimal amount of viable myocardium is supplied by the RPDA 2, 1
• Unfavorable lesion morphology: When the lesion characteristics predict low likelihood of procedural success 2, 1
• High procedural risk: When patient comorbidities create excessive risk of procedure-related morbidity or mortality 2, 1

Special Considerations for RPDA Intervention

Multivessel Disease Context

When the RPDA lesion is part of multivessel coronary disease, the decision becomes more nuanced:

• If the patient also has left main or complex 3-vessel disease (SYNTAX score >22): CABG should be strongly favored over PCI, and isolated RPDA intervention would be inappropriate 1, 3
• Diabetic patients with multivessel disease including RPDA: CABG provides superior survival benefit and should be the standard therapy 3, 4
• Single-vessel RPDA disease or non-complex multivessel disease: PCI is appropriate when anatomic and clinical criteria are met 1

Technical Success Rates

Contemporary data demonstrates that PCI can be successfully performed on complex coronary lesions, including posterior descending arteries, with technical success rates of 91.7-98.8% and clinical success rates of 93.3-100% in experienced centers. 5, 6 However, the RPDA is typically a smaller caliber vessel, which may influence long-term patency rates.

Common Pitfalls to Avoid

• Never intervene on the RPDA without documented ischemia in stable patients: Multiple randomized trials show no mortality or MI reduction compared to optimal medical therapy alone when ischemia is not documented 2
• Avoid ad hoc PCI on the RPDA in complex multivessel disease: This prevents proper Heart Team discussion about whether CABG would be superior, particularly in diabetic patients 1, 4
• Do not perform PCI if the patient cannot tolerate dual antiplatelet therapy: The required duration is at least 1 month for bare metal stents and ideally 12 months for drug-eluting stents 1, 2

Procedural Planning

When PCI on the RPDA is indicated:

• Ensure adequate antiplatelet therapy: Aspirin plus a P2Y12 inhibitor (clopidogrel, ticagrelor, or prasugrel) should be administered before the procedure when feasible 1
• Minimize contrast volume: Particularly in patients with chronic kidney disease (creatinine clearance <60 mL/min) 1
• Consider radial access: This approach reduces major bleeding and mortality compared to femoral access in most cases 1