Management of Patients with CAD

receiving Invasive Interventions

PCI
Prepared by: Ahmad Khalil Al-Sadi (RN, MSN, CNS)
 More than 1 million PCI procedures were performed
worldwide in 2000, and more than 62,000 in the UK
in 2004.
 In 2000, more than 500,000 percutaneous coronary
interventions (PCIs) were performed in the United
States. By 2004, the number exceeded 650,000 in
the United States with rapid growth in other
developed countries. Worldwide, the number of
PCIs continues to increase annually.
 More than 1 million PCI procedures were performed
worldwide in 2000, and more than 62,000 in the UK
in 2004.
 WHAT IS PCI
Percutaneous Coronary
 The term is used Intervention
to describe various procedures that
can be used to mechanically improve myocardial
perfusion without resorting to surgery.

1) PTCA
2) Stent implantation
3) Atherectomy
 Angioplasty

 Angioplasty is the mechanical alteration of a

narrowed or totally obstructed vascular lumen,
generally caused by atheroma (the lesion of
atherosclerosis).
 The term derives from the roots "Angio" or vessel
and "plasticos" fit for molding.
 The term has come to include all manner of vascular
interventions typically performed in a minimally
invasive or percutaneous method.
 Percutaneous Transluminal
Coronary Angioplasty [PTCA]
 A long catheter is passed
from femoral artery up to
the openings of the
coronary arteries.
 Using radioopaque dye
and fluoroscopy, areas of
stenosis can be identified.
 A deflated balloon is
passed over a guidewire
to a site of stenosis, where
the balloon is inflated.
 GOALS OF PTCA
 Improve blood flow to myocardium-”cracking”
the atheroma
 Several inflations & balloon sizes may be required to
achieve desired goal, usually defined as less <20%
residual stenosis
 Advantages of PTCA
 Performed under local anesthesia
 Provides alternative to surgery
 Eliminates recovery from thoracotomy surgery
 Pt is ambulatory within 24hrs
 1-3 Days vs 5-7 post CABG
 PTCA: Outcome

• Cannot always successfully perform procedure

– Diffuse disease
– Total occlusion
– Calcified disease
• Restenosis
– Occurs in 25-54% of patients
– Usually occurs within 6 months
 Mechanism of angioplasty
 The enlargement of the vessel lumen through a
mechanism of atheromatous plaque compression.
 Most of improvement in luminal diameter following
balloon angioplasty results from stretching of the vessel
wall and partial disruption of not only the intimal plaque
but also the media and adventitia, resulting in enlargement
of the lumen and the outer diameter of the vessel.
 Axial redistribution of plaque material also contributes to
improvements in lumen diameter.
 Atherectomy devices and, subsequently, intracoronary
stents were developed, in part, to decrease the early and
late loss in luminal diameter observed with conventional
balloon angioplasty.
 Indications
 Acute coronary syndromes − PCI for ST-elevation
myocardial infarction (STEMI) is more efficacious and
safer than thrombolysis.
 In non-ST-elevation myocardial infarction (NSTEMI)
and unstable angina, a strategy of early mechanical
revascularization reduces later coronary events and
mortality.
 Stable angina − PCI should be considered in patients
with angina despite medical therapy (or in those in
whom medication is poorly tolerated because of side-
effects) or high-risk features on non-invasive testing.
 Angiographic indications and
contraindications to PTCA

Indications:
Hemodynamically significant lesion in a vessel
serving viable myocardium (vessel diameter >1.5
mm)
Pts with lesions >70% stenosis placing large areas of heart
At risk for ischemia.
 Relative contraindications
 Left main stenosis or left main equivalent stenosis
(Coronary artery bypass graft [CABG] surgery is still the
preferred treatment for left main stenosis. However, this
area is rapidly evolving toward safe and feasible PCI
options.)
 Chronic total occlusion (CTO) with the following:
 No proximal stump visible
 Extensive bridging collaterals present

 Diffusely diseased small-caliber artery or vein graft

 Other coronary anatomy not amenable to percutaneous
intervention
 Once positioned, the balloon is inflated for
about 10 to 30 seconds (occluding coronary
flow). The balloon is then deflated and
withdrawn from the coronary circulation into
the guiding catheter. Injection of contrast into
the coronary artery during cine acquisition
enables assessment of the result.
 Stents
 Small stainless steel “scaffold” supports artery
and enables blood flow.
 Delivered over balloon catheter.
 Half of PTCA
• procedures now include stenting.
 Metallic stents
Tiny, cylindrical, expandable tubes of metallic mesh,
to overcome the restenosis of balloon angioplasty.
• Stainless steel or nitinol.
 Drug-eluting stents

Metallic stents coated with pure drug or polymer

matrix containing drug.
•Complications:
– Thrombosis (antiplatelet agents are required)
– Restenosis (cell proliferation should be suppressed)
 CURRENT
INTERVENTIONAL CARDIAC
PROCEDURES
 Intracoronary
Stents
Used to prop or support
the arterial wall. Used to
keep vessels open.
Anticoagulant &
antiplatelet meds given
to reduce risk for
thrombus formation at
site
 an intracoronary stent (a cylindrical steel mesh) is
then deployed. Inflation pressures used for stent
deployment are usually higher (12–20 atmospheres).
After about 15–30 seconds, the balloon is deflated
and withdrawn into the guiding catheter, leaving the
stent mesh pressed firmly against the walls of the
coronary artery. Advances in stent design are such
that it is now often possible to position a stent across
a tight stenosis without pre-dilating the lesion (so-
called ‘primary stent implantation’).
 Broad indications for Stent
implantation
 Acute or threatened artery closure following
balloon angioplasty, resulted in decreased the
need for emergency surgery.
 Elective stent implantation for optimizing the
initial and longer-term revascularization result.
 Comparing Stents with Balloon
Angioplasty
 Reduced adverse cardiac events with stents by about
30 % in the 6 mos following the procedure.
 Decrease risk and need for repeat revascularization of
about 50%.
 Stents decrease restenosis by providing the largest
intimal angiographic gain and by preventing early
recoil and late vessel constriction.
 Higher procedural success rate, long term patency,
and improved in-hospital clinical outcome with
stenting vein grafts.
 Problems with Stenting
 Neointimal hyperplasia
􀂃 Healing process
􀂃 Cellular proliferation
 Thrombosis

􀂃 Blood clotting
􀂃 Response to foreign body
 Restenosis

􀂃 Re-narrowing of the vessel

 Drug-eluting stent
 multiple types of DESs are available, with the 2 most
commonly used in the United States being the sirolimus
(Cypher) stent (SES) and the paclitaxel (Taxus) stent (PES).
 These stents comprise a metal stent with a polymer that
elutes a drug that reduces neointimal hyperplasia. Newer
stent platforms are evolving with more uniform drug
delivery systems and with the ability for some stents to store
different drugs for local intracoronary delivery.
 SES and PES have both been extensively tested in a wide
spectrum of coronary lesions, all of which have
demonstrated significant reductions in restenosis and target
lesion revascularization (TLR) rates when compared with
bare metal stents.
 RAVEL: 1-Year survival free of MI or
repeat revascularization

• Controlled release of cell growth inhibitors from stents has

shown promise in preventing restenosis. Most experience
has accrued with sirolimus.
• The Randomized Study with the Sirolimus-Coated Bx
Velocity Balloon-Expandable Stent in the Treatment of
Patients with de Nova Native Coronary Artery Lesions
(RAVEL) evaluated a stent coated with a 5-mm thick layer
of a sirolimus-polymer matrix. The stent releases active
drug over a period of 30 days following placement.
•
1-year data in 238 patients with stable/unstable angina or
silent ischemia, a single primary target lesion in a native
coronary vessel of 2.5 to 3.5 mm in diameter, stenosis of
51% to 99% of luminal diameter, and a TIMI flow rate >1.
Study subjects were randomized to receive the sirolimus-
eluting stent or an uncoated stent.
• The estimate of survival free from MI and repeat
revascularization. The difference between the two groups
was entirely due to greater need for repeat
revascularization in the uncoated-stent group ( 22.8%)
versus the sirolimus-eluting stent group (0%).
• None of the sirolimus-eluting stent group had acute,
subacute, or late thrombosis, which suggested to the
RAVEL investigators that re-endothelialization had
occurred.
 TAXUS I: Results at 6 and 12 months

• Encouraging preliminary results on preventing

restenosis have been reported with a paclitaxel-eluting
stent in the TAXUS I trial.
• To evaluate a stent coated with a paclitaxel-polymer
matrix that releases active drug over 10 days, the
study enrolled 61 patients with lesions of 50% to 99%
luminal diameter in a native coronary vessel of 3.0
mm to 3.5 mm in diameter. Subjects were randomized
to the paclitaxel-eluting stent or an uncoated stent.
•
 TAXUS I: Results at 6 and 12 months

• As shown, at 6 months there was a significant

improvement in the paclitaxel eluting stent
compared with the uncoated stent with regard to
diameter stenosis within the stented area, with
no differences at the proximal and distal edges.
• At 12 months, the rate of target-lesion PCI was
10% in the control group and 0% in the
paclitaxel-eluting stent group.
 Comparison of Therapy

• Hospital Stay:
– CABG – 4-7 days
– Angioplasty – 1-2 days
– Stent – 1-2 days
• Restenosis:
– CABG – 5-6%, usually after 5 years
– Angioplasty – 25-45%, usually within 6 months
– Stent – 15-20%, usually within 6 months
 Comparison of Therapy

• Cost
– CABG $35,000
– Angioplasty $17,000
– Stent $19,000
• Cost-effectiveness
– Additive procedures:
• Within 5 years, 20-40% of patients have second PTCA, 25% have
CABG
– Additive costs:
• 0 years: per patient costs of PTCA 30-50% those of CABG
• 1 year: 50-60%
• 3 years: 60-80%
• >3 years: >80%
 PCI
COMPLICATIONS
 Allergic reactions to contrast dye and
contrast nephropathy
 Allergic reactions related to iodine-based contrast agents for
angiographic imaging are classified as minor (hives, rash),
moderate (urticaria, bronchoconstriction), or severe
(anaphylactoid reaction [as opposed to anaphylactic
reaction] with hemodynamic collapse).
 In patients with a history of contrast reaction, the risk for
repeated anaphylactoid reaction is generally reported to
range from 17% to 35%.
 Previous adverse reactions to shellfish or seafood in general
are believed to be associated with future anaphylactoid
reaction to iodine-based contrast.
 Most recent studies have defined contrast
nephropathy as an increase in serum creatinine
concentration of 25% or an absolute increase of 44
mol/L (0.5 mg/dL).
 Contrast nephropathy usually first manifests as an
elevation in creatinine concentration 24 to 48 hours
after the procedure that peaks 3 to 5 days after the
procedure.
 Patient-related factors associated with an increased
risk for contrast nephropathy include diabetes;
preexisting renal insufficiency; and, possibly,
reduced intravascular volume status.
 In-stent restenosis (ISR)

• Pooled data from six trials indicate that the rate of in-
stent restenosis steadily increases over the first year,
regardless of how restenosis is defined.
• At 12 months, 12% of patients require target lesion
revascularization, almost double the rate at 6 months.
• At 12 months, 15.8% of patients have target vessel
failure.
• These findings underscore the importance of at least
12-month follow-up when assessing strategies for
reducing in-stent restenosis.
 Restenosis is the process by which a treated arterial narrowing
recurs over time.
 The restenosis process is now believed to occur because of
negative arterial remodeling (arterial “constriction”) and
intimal hyperplasia, combined with other complex processes.
 Factors associated with an increased risk for restenosis include
diabetes; unstable or severe angina at the time of PCI; lesions
in the left anterior descending artery or in a saphenous vein
graft; total length of the lesion treated; chronically occluded
arteries; previously treated lesions; and factors related to
technical aspects of the procedure itself, most notably
minimum luminal diameter immediately afterward.
 The restenotic process occurs over the first 1 to 6 to 8 months
after PCI.
 The presenting symptom for most patients with
restenosis is exertional angina (25% to 85%); fewer
patients (11% to 41%) present with unstable angina,
and presentation with acute MI is rare (1% to 6%).
 Stents have been demonstrated to decrease
restenosis rates in saphenous vein bypass grafts, in
chronically occluded arteries, and in patients treated
with primary angioplasty for acute MI.
 Drug-eluting stents dramatically reduces the rates of
restenosis compared with bare-metal stents.
 Stent Thrombosis
 A catastrophic complication, associated with 30-day
mortality rates in recent series of 20.8% to 26%.
 Most frequently occurs in the first days to weeks after stent
implantation.
 Patients usually present with severe chest pain and often
present with ST-segment elevation.
 Patients treated with bare-metal (non– drug-eluting) stents
should receive 4 weeks of clopidogrel in addition to aspirin
to prevent stent thrombosis.
 Because of concern that late stent thrombosis may develop
in patients who are treated with drug-eluting stents, most
recent trials have extended clopidogrel treatment to 3 to 6
months after PCI, in addition to aspirin therapy.
 Stent infection
 Foreign body implantation predisposes to the
development of infections by damaging or invading
epithelial or mucosal barriers, by supporting growth
of micro-organisms and by impairing host defense
mechanisms.
 Manifested within the first four weeks after stent
implantation with fever being the clinical hallmark,
chest pain, and positive blood cultures.
 Stent infection should be suspected and blood cultures
should be withdrawn in all patients presenting with
fever within the first weeks after coronary stent
implantation even in the absence of chest pain, ECG
abnormalities or elevation of cardiac enzymes.
 verification of the local infection by cardiac imaging
modalities, including transthoracic and transoesophageal
echocardiography, coronary angiography, computed
tomography, and magnetic resonance imaging.
 Compliance with current standards for the prevention of
infections during cardiac catheterisation are measures to
prevent infection include the removal of hair from the
puncture site, application of antiseptic to the skin, and the
use of sterile drapes. Operators should perform appropriate
hand washing, wear a sterile gown and sterile gloves and a
generally sterile environment should be maintained during
the procedure.
 Rapid institution of antibiotic treatment represents the
mainstay of therapy, and surgical drainage of the infective
focus including stent removal may be necessary.
 Abrupt vessel closure
May occur in as many as 5% of balloon angioplasty
cases and typically develops when compression of
the true lumen by a large dissection flap occurs,
thrombus formation, superimposed coronary
vasospasm, or a combination of these processes.
The presence of large coronary dissections
immediately after balloon angioplasty is associated
with a 5-fold increase in the risk of abrupt closure.
The use of intracoronary stents and new antiplatelet
drugs has decreased the incidence of abrupt closure
significantly (to <1%).
 Factors predictive of abrupt vessel
closure
 Preprocedure:    
 Clinical factors: Female gender,  Unstable angina, Insulin-
dependent diabetes mellitus, Inadequate antiplatelet therapy.
 Angiographic factors: Intracoronary thrombus,  >90%
stenosis, Stenosis length 2 or more luminal diameters,
Stenosis at branch point, Stenosis on bend ( 45°).
  Right coronary artery stenosis.
 Postprocedure: 

Intimal dissection >10 mm 

Residual stenosis >50%
 Transient in-lab closure
Residual transstenotic gradient 20 mm Hg     
 Myocardial Infarction
 can occur during PCI because of coronary dissection,
abrupt vessel closure, thrombotic occlusion of the epicardial
vessel, distal embolization of thrombus or atheromatous
material to the microcirculation, side branch occlusion,
coronary spasm, or a combination of events.
 The incidence of MI, defined primarily as CK-MB
concentrations elevated to more than two to three times
the upper limit of normal, generally ranges between 5%
and 30%.
 Serial CK and CK-MB measurements (6 to 8 and 16 to 24
hours after the procedure) should be obtained in patients
with suspected ischemia during PCI.
 Emergency Coronary Bypass Surgery
and Death
 Recent data demonstrate that the need for emergency
CABG has decreased since the introduction of coronary
stents and that CABG rates are currently less than 1%.
Death is similarly rare, most recent registries and
clinical trials report mortality rates of less than 1%.
 Factors associated with increased mortality rates during
PCI include advanced age, female sex, diabetes,
previous MI, multivessel disease, left main or
equivalent coronary disease, a large area of
myocardium at risk, preexisting left ventricular
function, and preexisting renal insufficiency.
 Factors associated with increased
mortality for angioplasty
 Clinical Factors:
    Female gender, Age >65 years, Unstable
angina, Congestive heart failure, Chronic renal
failure.
  Angiographic Factors:

Left main coronary disease, Three-vessel disease,

Left ventricular ejection fraction < 0.30.
 Risk index: Myocardial jeopardy score, Proximal
right coronary stenosis, Collaterals originate from
dilated vessel.
 Vascular Complications
 overt bleeding with a decrease in hemoglobin level of at
least 30 to 50 g/L (3 to 5 g/dL), need for blood transfusion,
or retroperitoneal bleeding.
 In current clinical practice, as evidenced by results of recent
interventional trials, rates of major bleeding complications
are low (0.7% to 1.7%).
 Insertion of vascular sheaths may produce groin or
retroperitoneal hematomas.
 Groin hematomas may present with localized pain, lower-
extremity edema due to femoral vein compression, or
neurologic symptoms due to compression of the femoral
nerve, palpation of localized swelling or tenderness in the
area, or loss of sensory or motor function.
 Retroperitoneal hematoma should be suspected in
patients with unexplained hypotension and/or a
marked decrease in hematocrit, may experience
flank, abdominal, or back pain.
 Most retroperitoneal hematomas can be treated
conservatively with discontinuation or reversal of
anticoagulation and antiplatelet therapy and with
blood transfusions alone when necessary; only 16%
of patients require surgery.
 Indications for surgical intervention include
persistent hypotension, decreasing hematocrit
despite transfusion, or femoral neuropathy (due to
nerve compression).
 A femoral pseudoaneurysm is a communication
between the femoral artery and the overlying
fibromuscular tissue, resulting in a bloodfilled
cavity. The reported incidence ranges from 0.5% to
6.3%.
 Groin tenderness, a palpable pulsatile mass, and/or
new bruit in the groin area should prompt
examination by Doppler flow imaging.
 Can be treated with ultrasound-guided compression,
ultrasound-guided thrombin injection, or surgical
repair.
Arterial pseudoaneurysm
 An arteriovenous (AV) fistula can result from sheath
mediated communication between the femoral artery
and femoral vein, may be suggested by the presence
of a systolic and diastolic bruit and confirmed by
Doppler ultrasonography.
 Reported incidence ranges from 0.2% to 2.1%.

 Can be treated with conservative therapy (careful

observation) in most patients or with ultrasound-

guided compression, surgical repair, or
percutaneous implantation of covered stents if
necessary.
 Characteristics of type A, B, and C
lesions
 Type A lesions (minimally complex) :   Discrete (length
<10 mm)    Concentric    Readily accessible    Nonangulated
segment (<45°)    Smooth contour    Little or no
calcification    Less than totally occlusive    Not ostial in
location    No major side branch involvement. Absence of
thrombus
 Type B lesions (moderately complex)*:    Tubular (length
10–20 mm)    Eccentric    Moderate tortuosity of proximal
segment.    Moderately angulated segment (>45°,
<90°).    Irregular contour    Moderate or heavy
calcification    Total occlusions <3 mo old    Ostial in
location    Bifurcation lesions requiring double guide
wires    Some thrombus present
 Type C lesions (severely complex):    Diffuse
(length >2 cm)    Excessive tortuosity of proximal
segment. Extremely angulated segments
>90°    Total occlusions >3 mo old and/or bridging
collaterals. Inability to protect major side
branches Degenerated vein grafts with friable
lesions

 Although the risk of abrupt vessel closure may be

moderately high with Type B lesions, the likelihood
of a major complication may be low in certain
instances such as in the dilation of total occlusions
<3 mo old or when abundant collateral channels
supply the distal vessel
OTHER INTERVENTIONAL
CARDIAC PROCEDURES
 Although coronary stents are the mainstay for
treatment for obstructive coronary artery disease,
several adjunctive devices and techniques are
available for coronary intervention
 Laser Angioplasty

Uses pulsed laser energy to vaporize plaque & reopen

blocked arteries
 Directional coronary atherectomy
 Used to debulk coronary plaques. A steel fenestrated cage housing a
cup-shaped blade is positioned against the coronary lesion by a low-
pressure positioning balloon, allowing any protruding plaque to be
removed. Atherectomy is typically followed by balloon dilation and
stenting.
 Major complication rates associated with directional atherectomy are
low and similar to conventional balloon angioplasty.
 Other complications (eg, distal embolization of plaque, transient side-
branch occlusion, coronary vasospasm, the no reflow phenomenon,
non–Q-wave MI) are greater with DCA than with balloon angioplasty.
 Because of the increased complication rates and the greater technical
demands of DCA compared with balloon angioplasty or stenting, the
use of DCAs has greatly decreased in recent years.
 Directional coronary atherectomy has been
shown to improve acute angiographic results
and facilitate both balloon angioplasty and
coronary stenting in select lesions.
 It has not been shown to reduce the need for
repeat target lesion revascularization, a clinical
measure of restenosis. Its greatest value is for
use in lesions in which the physical removal of
plaque at ostial or bifurcation lesions will
allow successful balloon angioplasty and
coronary stenting.
 Rotational atherectomy catheter
(Rotablator)
 Is a device designed for the removal of plaque from
coronary arteries. This device, which has a diamond-
studded burr at its tip, rotates at about 160,000 rpm and is
particularly well suited for ablation of calcific or fibrotic
plaque material .
 Relies on plaque abrasion and pulverization. Rotational
atherectomy is successful in 92-97% of these cases, with a
low incidence of major complications. It causes
dislodgement of particles into the microcirculation, which
occasionally may lead to infarction and no reflow.
Currently, the use of rotational atherectomy is largely
confined to fibrotic or heavily calcified lesions that can be
wired but not crossed by a balloon catheter.
 Used to facilitate stent delivery in complex
lesions, especially when balloon angioplasty
alone has failed.
 plays an important role in the treatment of
ostial and bifurcation lesions.
 The Excimer Laser, Rotational Atherectomy,
and Balloon Angioplasty Comparison
(ERBAC) Study showed rotational
atherectomy was associated with a higher
short-term success rate than balloon
angioplasty (90% vs 80%), but major ischemic
complications and repeat revascularization
were higher 6 months after treatment (46% vs
37%).
 RHEOLYTIC THROMBECTOMY
 Rheolytic thrombectomy has become a useful tool for the
removal of coronary thrombi before coronary stenting.
 The rheolytic thrombectomy catheter works by forcing
saline out of the distal tip of the catheter at high flow rates
into a proximal lumen of the catheter. The high saline flow
rates allow for suction of thrombus into the proximal lumen
by the Venturi effect .
 Although rheolytic thrombectomy has not been shown to
reduce restenosis, it is extremely effective in clearing
thrombus and facilitating balloon angioplasty or coronary
stenting .
 It is of particular value in the treatment of acute myocardial
infarction, sub-acute stent thrombosis, and lesions in
degenerated saphenous vein grafts.
 DISTAL PROTECTION DEVICES

 Used to prevent embolization of particulate matter

during percutaneous coronary intervention.
 It is approved for percutaneous coronary
intervention on saphenous vein grafts, occludes the
vein graft with a balloon during intervention and
allows for removal of particulate matter from the
graft by means of an aspiration catheter, resulted in
53% fewer periprocedural ischemic complications
than during vein graft intervention without distal
protection.
 Nursing Care of the Client
having a Coronary Angiogram/or
PTCA
PREPROCEDURE CARE
 Informed consent, Check for Allergies
POSTPROCEDURE
 Hold Aspirin, Anti-platelet drugs & CARE
any other anti-coagulants  VS Q15x1; q30x1,q2
 NPO 4- 8 hrs prior  BR, HOB 20-30O
 Give all meds-especially cardiac meds  Check pressure drsg.
with sips of H20
Over arterial site
 Baseline Head-Toe Assessment,
including peripheral pulses  Immobilize extremity.
 Pt Instruction: They will be awake  Inc. fluid intake, unless
during procedure, takes 1-2hrs. May contraindicated
experience a momentary sensation of  Assess for CP &
warmth [“hot flash”] & metallic taste
when dye injected. Dysrhythmias
 Discharge Instructions
 Medications: new drug and potential side effect.
 Activity:
 bath/shower.
 Not lifting anything over 5kg
 Not driving themselves home
 Return to work & resume sexual activity.
 Things to watch:
 Groin site re-bleed
 Signs of infection over the site
 Chest pain.
 Patient basic needs
 Alteration in comfort
 Actual/potential alteration in hemodynamic
status.
 Anxiety and lack of knowledge.