Percutaneous Coronary Intervention (PCI)

BY: Huson Amin

Outline:

• Definition.• History.• Indication.• Contraindication.• Procedure.• Nursing care (pre- post).• Complication.

DEFINITION:

Percutaneous Coronary Intervention (PCI, formerly known as angioplasty with stent) is a non-surgical procedure that uses a catheter (a

thin flexible tube) to place a small structure called a stent to open up blood vessels in the

heart that have been narrowed by plaque buildup, a condition known as atherosclerosis.

though it was developed and originally performed by interventional radiologists.

History

• Coronary angioplasty, also known as percutaneous transluminal coronary angioplasty (PTCA), because it is done through the skin and through the lumen of the artery, was first developed in 1977 by Andreas Gruentzig.

Indication for PCI :

• Acute ST-elevation MI (STEMI) • Non–ST-elevation acute coronary syndrome (NSTE-

ACS) • Stable angina • Anginal equivalent (eg, dyspnea, arrhythmia, or

dizziness or syncope) • Asymptomatic or mildly symptomatic patient with

objective evidence of a moderate-sized to large area of viable myocardium or moderate to severe ischemia on noninvasive testing

Contraindication for PCI:

• Clinical contraindications for PCI include intolerance of chronic antiplatelet therapy and the presence of any significant comorbid conditions that severely limit patient lifespan (this is a relative contraindication).

PCI procedure:

procedures done during a percutaneous coronary intervention include:Balloon angioplasty.• Implantation of stents• Rotational or laser atherectomy• Brachytherapy (use of radioactive source to

inhibit restenosis.

PCI technique:

• Access into the femoral artery in the leg (or, less commonly, into the radial artery or brachial artery in the arm) is created by a device called an "introducer needle". This procedure is often termed percutaneous access.

• Once access into the artery is gained, a "sheath introducer" is placed in the opening to keep the artery open and control bleeding.

• Through this sheath, a long, flexible, soft plastic tube called a "guiding catheter" is pushed. The tip of the guiding catheter is placed at the mouth of the coronary artery. The guiding catheter also allows for radio-opaque dyes (usually iodine-based) to be injected into the coronary artery, so that the disease state and location can be readily assessed using real time X-ray visualization.

• During the X-ray visualization, the cardiologist estimates the size of the coronary artery and selects the type of balloon catheter and coronary guidewire that will be used during the case. Heparin (a "blood thinner" or medicine used to prevent the formation of clots) is given to maintain blood flow.

• The coronary guidewire, which is an extremely thin wire with a radio-opaque flexible tip, is inserted through the guiding catheter and into the coronary artery. While visualizing again by real-time X-ray imaging, the cardiologist guides the wire through the coronary artery to the site of the stenosis or blockage.

• While the guidewire is in place, it now acts as the pathway to the stenosis. The tip of the angioplasty or balloon catheter is hollow and is then inserted at the back of the guidewire—thus the guidewire is now inside of the angioplasty catheter. The angioplasty catheter is gently pushed forward, until the deflated balloon is inside of the blockage.

•The balloon is then inflated, and it compresses the atheromatous plaque and stretches the artery wall to expand

• If an expandable wire mesh tube (stent) was on the balloon, then the stent will be implanted (left behind) to support the new stretched open position of the artery from the inside

• Newer drug-eluting stents (DES) are traditional stents coated with drugs, which, when placed in the artery, release certain drugs over time. These types of stents have been shown to help prevent restenosis of the artery

• Umirolimus, zotarolimus, sirolimus, everolimus, and paclitaxel

Nursing care pre PCI

• If the patient is an “In-patient” on the unit, try to arrange a visit from the nurse from the cath lab. Among the things she should accomplish is to ; introduce herself, advise the patient as to what time the procedure may occur, check the patients chart for:

• pre-cath orders, allergies, signed permission, verify counseling by the physician and establish the patients knowledge level.

• Physicians orders may include fasting for 3 to 8 hours before the procedure and withholding or decreasing the dosage of scheduled medications (including insulin, antihypertensive drugs, and diuretics-unless otherwise instructed by a physician).

• Before sending the patient to the cardiac cath lab make

sure the pre-cardiac cath checklist is completed and assess them for allergies, especially to iodine or shellfish; some contrast material often contain iodine.

Nursing care post PCI

• The hemodynamic stability of the patient should be assessed immediately when the patient returns from the cath lab. The initial assessment should include vital signs, O2 level, urine output, strength and presence of pulses in the extremities.

• Assess the affected puncture site. Followed by assessment of cardiac, respiratory, pulmonary, and gastrointestinal.

• When the patient returns they will be placed on bedrest with the

head of the bed no higher than 30 degrees (6-12 hrs). The patients affected extremity must be kept straight.

• Once the patient is fully awake and their condition warrants, encourage the patient to drink fluids during the first 12 hours post-cath, unless contraindicated by physician.

• Maintain hourly intake and output.

• If the patients puncture site starts to bleed, pressure should be held just above the insertion site until bleeding stops. If able, find the pulse just above the insertion site and apply pressure until hemostasis is obtained. Note: Do Note obliterate the distal pulses.

Complications of PCI

•Intravascular contrast:• Sever delayed reactions have been known to

occur 30-60 minutes after administration. Rare undesirable reactions, ranging from mild nausea to life threatening anaphylaxis have occurred.

Intravascular contrast complication:

• Hemodynamic effects- Transient impairment in ventricular contractility, relaxation and hypotension.

• Electrophysiologic effects- Bradycardia, AV Block, ST segment and T wave changes, prolonged QT interval and Ventricular tachycardia/fibrillation have been attributed to the calcium channel binding buffers used in contrast media.

• Dye induced renal dysfunction is the most common cause of renal insufficiency.

Complications / Risks Associated with Heart Catheterization:

The main risks of the procedure are:• Bruising at the access site.• Trauma to the vein.• Puncturing the lung if the neck or chest veins

are used.• Very rare instances a patient may suffer cardiac

arrhythmias, cardiac tamponade, low blood pressure, infection, or embolism caused by blood clots at the tip of the catheter

• The risk of complications is higher in:• People aged 65 and older• People who have kidney disease or diabetes• Women• People who have poor pumping function in

their hearts• People who have extensive heart disease and

blockages

REFRENCES– Tullio Palmerini; Giuseppe Biondi-Zoccai; Letizia Bacchi Reggiani; Diego Sangiorgi; Laura

Alessi; Stefano De Servi; Angelo Branzi; Gregg W. Stone,; Biondi-Zoccai; Reggiani; Sangiorgi; Alessi; De Servi; Branzi; Stone (August 2012). "Risk of Stroke With Coronary Artery Bypass Graft Surgery Compared With Percutaneous Coronary Intervention". Journal of the American College of Cardiology 60 (9): 798–805. Stroupe KT, Morrison DA, Hlatky MA, Barnett PG, Cao L, Lyttle C, Hynes DM, Henderson WG (September 2006). "Cost-effectiveness of coronary artery bypass grafts versus percutaneous coronary intervention for revascularization of high-risk patients". Circulation 114 (12): 1251–1257.

– b Kones, R (Sep 7, 2010). "Recent advances in the management of chronic stable angina II. Anti-ischemic therapy, options for refractory angina, risk factor reduction, and revascularization.". Vascular health and risk management 6: 749–74..

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– Elmariah, Sammy; Mauri, Laura; Doros, Gheorghe; Galper, Benjamin Z; O'Neill, Kelly E; Steg, Philippe Gabriel; Kereiakes, Dean J; Yeh, Robert W (November 2014). "Extended duration dual antiplatelet therapy and mortality: a systematic review and meta-analysis". The Lancet.