INVASIVE CORONARY ARTERY PROCEDURES

Percutaneous Coronary Interventions

Types of Procedures
Invasive interventional procedures to treat CAD include PTCA, intracoronary stent implantation,
atherectomy, and brachytherapy. All of these procedures are classified as PCIs.
Percutaneous Transluminal Coronary Angioplasty
In PTCA, a balloon-tipped catheter is used to open blocked coronary vessels and resolve ischemia. It is
used in patients with angina and as an intervention for ACS. Catheterbased interventions can also be
used to open blocked CABGs. The purpose of PTCA is to improve blood flow within a coronary artery by
compressing and “cracking” the atheroma. The procedure is attempted when the interventional
cardiologist believes that PTCA can improve blood flow to the myocardium.
PTCA is carried out in the cardiac catheterization laboratory. Hollow catheters called sheaths are
inserted, usually in the femoral artery (and sometimes femoral vein), providing a conduit for other
catheters. Catheters are then threaded through the femoral artery, up through the aorta, and into the
coronary arteries. Angiography is performed using injected radiopaque contrast agents (commonly called
dye) to identify the location and extent of the blockage. A balloon-tipped dilation catheter is passed
through the sheath and positioned over the lesion. The physician determines the catheter position by
examining markers on the balloon that can be seen with fluoroscopy. When the catheter is properly
positioned, the balloon is inflated with high pressure for several seconds and then deflated. The pressure
compresses and often “cracks” the atheroma (Fig. 28-8). The media and adventitia of the coronary artery
are also stretched. Several inflations and several balloon sizes may be required to achieve the goal,
usually defined as an improvement in blood flow and a residual stenosis of less than 20% (Urden, Stacy
& Lough, 2006). Other measures of the success of a PTCA are an increase in the artery’s lumen and
no
clinically obvious arterial trauma. Because the blood supply to the coronary artery decreases while the
balloon is inflated, the patient may complain of chest pain and the ECG may display ST-segment
changes. Intracoronary stents are usually positioned in the intima of the vessel to maintain patency after
the balloon is withdrawn.
Coronary Artery Stent
After PTCA, the area that has been treated may close off partially or completely, a process called
restenosis. The intima of the coronary artery has been injured and responds by initiating an acute
inflammatory process. This process may include release of mediators that leads to vasoconstriction,
clotting, and scar tissue formation. A coronary artery stent may be placed to overcome these risks. A
stent is a metal acute closure. The stent is positioned over the angioplasty balloon. When the balloon is
inflated, the mesh expands and presses against the vessel wall, holding the artery open. The balloon is
withdrawn, but the stent is left permanently in place within the artery (see Fig. 28-8). Eventually,
endothelium covers the stent and it is incorporated into the vessel wall. Some stents are coated with
medications, such as sirolimus (Rapamune) or paclitaxel (Taxol), which may minimize the formation of
thrombi or scar tissue within the stent. These drug-eluting stents have increased the success of PCI
(Fennessy & Borden, 2006). Because of the risk of thrombus formation within the stent, the patient
receives antiplatelet medications, usually aspirin and clopidogrel. The clopidogrel is continued for at least
a month following placement of a bare metal stent and for a year following drug-eluting stents (King, et
al., 2007).