Percutaneous Coronary Intervention Flashcards
What are common pre-medications for PCI for anticoagulation, contrast nephropathy and no/slow reflow?
Anticoagulation:
Plavix loading 600mg + Aspirin 81mg or Ticagrelor 180mg + Aspirin 81mg or GpIIb/IIIa inhibitor (abciximab, eptifibatide, tirofiban) with lower ACT target
Heparin 100U/kg during procedure or Bivalirudin 1mg/kg bolus + 2.5 mg/kg/h for 4h
Contrast nephropathy prophylaxis:
Acetylcysteine 600mg q12h starting 12 h before procedure and continue until 12h after procedure
For no/slow reflow:
Nitroprusside - 30ug IC
Adenosine - 50ug IC
Verapamil/Diltiazem - 0.1-0.5mg IC
What are 5 risk factors for in-stent re-stenosis?
Use of POBA or BMS Smaller final lumen diameter T2DM Unstable angina HTN
What are the complications of PCI? Name 13
Distal:
Microembolization/slow reflow/no reflow
Macroembolization/MI
At lesion: Abrupt vessel closure Stent thrombosis Stent embolization Stent malposition Coronary dissection Coronary perforation In-stent restenosis Jailed vessel Cardiac tamponade
Proximal:
Ostial stenosis (from catheter manipulation)
Coronary dissection
Coronary perforation
Aortic:
Aortic dissection
Stroke
Whole body complication:
Contrast induced nephropathy
Contrast allergy
Access site Hematoma AV fistula Arterial pseudoaneurysm Bleeding
What is coronary flow reserve? What is the cutoff?
It is the ratio of coronary velocity at rest and at maximal coronary flow. Adenosine is used to obtain maximal coronary flow. The principle is that in significant lesions, autoregulation results in arteriolar dilation at rest, resulting in a reduced ratio. A ratio under 2.0 is considered significant
What is fractional flow reserve? What is the cutoff?
It is the ratio between pressure distal and proximal to the lesion. A FFR <0.80 and <0.75 in the LM is considered significant.
What are the catheters that are used in coronary angiography?
Judkins Right - comes in sizes 3.5-6, sizes are the distance between primary and secondary curves
Judkins Left - comes in sizes 3.5-6, sizes are the distance between primary and secondary curves
Amplatz Right - used for tougher to access coronaries, sits in the coronary sinuses, higher risk for dissection
Amplatz Left - used for tougher to access coronaries, sits in the coronary sinuses, higher risk for dissection
XB - stiffer, used for PCI, higher risk for dissection
Left coronary bypass - used for saphenous vein grafts
Pigtail - used for LV gram
LIMA catheter - used for LIMA
What is the classification of coronary artery perforations?
Grade I - a visible extraluminal crater without extravasation - Incidence 26% - non surgical 95% of time - rarely fatal
Grade II - pericardial or myocardial blushing - 50% - requires surgery 10% of the time - mortality 13%
Grade III - 1mm diameter perforation with contrast material streaming - 26% - requires surgery or covered stent - mortality 63%
What is the incidence of contrast induced nephropathy? When is the nadir of renal function?
What is the incidence of dialysis in CIN?
5-6% after coronary angiography
Nadir of renal function occurs 3-5 days after the procedure
Renal failure necessitating IHD is seen in about 10% of patients with CIN.
What strategies reduce risk of CIN?
Reduce contrast use, use iso-osmolar contrast, given fluids before during and after procedure, acetylcysteine administration
What are 7 risk factors for CIN?
CKD, anemia, hemodynamic instability, CHF, T2DM, PVD, age
What situations are slow reflow/no reflow phenomenon’s the most likely?
In acute MI and stenting of stenosed SVGs
What do DES require longer DAPT than BMS?
DES emit anti-growth agents which slow down the rate of intimal hyperplasia as well as endothelialization of the stent. Endothelialization of the stent is complete by 1-3 months in BMS and reduces the risk of stent thrombosis dramatically. In DES, this process takes longer and so DAPT is recommended for 6 months to 1 year.
What do the American guidelines recommend for DAPT after BMS and DES in SIHD and ACS?
In patients with stable ischemic heart disease (SIHD) treated with DAPT after drug-eluting stent (DES) implantation, P2Y12 inhibitor therapy with clopidogrel should be given for at least 6 months (Class I). In patients with SIHD treated with DAPT after bare-metal stent (BMS) implantation, P2Y12 inhibitor therapy (clopidogrel) should be given for a minimum of 1 month (Class I).
In patients with acute coronary syndrome (ACS) (non-ST elevation [NSTE]-ACS or ST elevation myocardial infarction [STEMI]) treated with DAPT after BMS or DES implantation, P2Y12 inhibitor therapy (clopidogrel, prasugrel, or ticagrelor) should be given for at least 12 months (Class I).
What do the American guidelines recommend in ACS who are being treated with DAPT and undergo CABG?
In patients with ACS (NSTE-ACS or STEMI) being treated with DAPT who undergo coronary artery bypass grafting (CABG), P2Y12 inhibitor therapy should be resumed after CABG to complete 12 months of DAPT therapy after ACS (Class I).
What do the American guidelines recommend after BMS and DES for elective non-cardiac surgery?
Elective non-cardiac surgery should be delayed 30 days after BMS implantation and optimally 6 months after DES implantation. In patients treated with DAPT after coronary stent implantation who must undergo surgical procedures that mandate the discontinuation of P2Y12 inhibitor therapy, it is recommended that aspirin be continued if possible and the P2Y12 platelet receptor inhibitor be restarted as soon as possible after surgery (Class I).
