What Is Percutaneous Coronary Intervention

Overview

Percutaneous Coronary Intervention (PCI) is a specific procedure used in the treatment of patients with coronary artery disease (CAD). If CAD is not left untreated, it might lead to more damage to the heart with an increased risk of having a heart attack.

The benefits of having a PCI are to help improve blood flow in the heart by reducing the symptoms of CAD and preventing heart attack or further damage to the heart.

Has your doctor told you or someone close to you requires a PCI? This article will explain the purposes of PCI and what you need to know about the PCI procedure.

Understanding coronary artery disease (CAD)

Coronary Artery Disease (CAD) is a type of heart condition that is caused by the heart not having enough oxygen and blood supply. It starts with the formation of atherosclerotic plaque in the vessel lumen in the coronary artery which hinders blood flow in and out of the heart.¹

According to some studies, it is the most common cause of death in the world and can be life-threatening if left untreated.²

Luckily, some treatments can be done to help improve the condition and prevent further complications or death from CAD.

This article will discuss percutaneous coronary intervention (PCI), one of the treatments used in people with CAD.

Purpose of percutaneous coronary intervention

Percutaneous Coronary Intervention (PCI) (also sometimes known as coronary angioplasty with stenting) is a specific type of treatment used for patients with CAD.

The main purpose of PCI is to help to improve blood supply to the heart. According to the British Heart Foundation, most patients usually get better after having this type of procedure and some have even returned back to their normal lives in as short a time as a few weeks after having a PCI. So, if your doctor has told you that you may need a PCI following CAD diagnosis, some of the reasons you might need one are to help with the following:

    Restoring blood flow to the heart

PCI procedure involves using a balloon to help stretch the heart vessels that have been narrowed or blocked by the plaque causing CAD. This helps to widen the blood vessels to allow or restore normal blood flow to your heart.³

    Alleviating symptoms of CAD

In most patients with CAD, the narrowing or blockage of the coronary artery (mainly the blood vessels) can sometimes make the blood forcefully try to flow through the heart, which can cause symptoms such as chest pains or breathlessness. With PCI, the blood vessels become stretched and widened, allowing blood to flow as normal. This helps to make symptoms much better in patients after having a PCI.⁴

    Preventing heart attacks and complications

In patients with CAD caused by the build-up of plaque, if the plaque ruptures, this may lead to a serious heart attack and more complications. The risk of getting a heart attack or further damage to the heart is reduced in patients who have had PCI as the blood vessels are opened up by removing the plaque blocking it.⁴

Procedure of percutaneous coronary intervention

So how is PCI performed? It starts with you and your doctor who will refer you to a cardiologist surgeon who is specialised in performing heart procedures in the hospital. 

You can choose where to have the treatment if you decide to have a PCI, your GP will usually recommend a hospital with experienced staff.

The hospital will handle your care from the pre-procedure preparations leading to the procedure and care after the procedure. This will help the cardiologist to be able to predict the possible outcomes so that the risks and benefits of PCI for you will be decided.⁵

    Pre-procedure preparations

        1. Informed consent

Before your referral to the specialist or any procedure is planned, your doctor will request your consent and check if you’re happy to continue with the next step. The hospital pre-assessment care team and your doctor will also recommend stopping any medications (if you’re taking any) before your procedure.

        2. Patient evaluation

Your specialist at the hospital will ask about your symptoms, review your blood tests, and check your family history to ensure that PCI is suitable for you. Some hospitals may ask you to attend a nurse-led pre-assessment clinic as the next step in your care pathway. Currently, this pre-assessment service will be either by telephone or face-to-face appointment.⁵

    During the procedure

        1. Catheter insertion

The cardiologist will inject a local anaesthetic, to numb the area of the point of the procedure then the specialist will access your artery using a sheath and catheters are then placed into your arteries using x-ray imaging. In some cases, the coronary arteries can be assessed using other medical imaging tools such as ultrasound or a pressure wire to find the degree of narrowing and the effect on blood flow through the coronary artery.⁶

When the catheters are placed in the correct positions, the specialist will inject a special dye (also known as contrast) to highlight blood vessels on X-ray images. As the dye is injected into your blood vessels, X-rays will be taken to provide the cardiologist with more detailed information about your arteries.

        2. Angioplasty and stent placement

The term "angioplasty" means a medical procedure that involves using a balloon to widen an artery that has become narrowed or blocked.

PCI helps to unblock the narrowed blood vessels using an X-ray examination and a special dye to highlight the X-ray images. When the site of the narrowing coronary arteries is shown, the coronary artery will be unblocked and widened using a small balloon, and a special metallic stent (wire-mesh) will be placed permanently in the arteries to keep the blood flowing to the heart.⁶

There are several places that the cardiologist can use as the insertion area and once the procedure is completed, the catheter will be removed from the insertion site. 

So, if the insertion site is your wrist, a compression device called the TR band will be placed around your wrist to stop any bleeding. However, if it’s your groin, a closure device or plug will be used to stop any bleeding.

    After the procedure

In some hospitals, you will be placed in a recovery ward under the watch of the cardiology team of doctors and nurses.

        1. Monitoring

In the hospital, the nursing staff will continue to record your pulse and blood pressure during this recovery period. If you feel unwell, please report to them at once. 

It is normal to feel some slight discomfort around your insertion site but make sure to report any unusual pain, bleeding and abnormal discoloration to your cardiologist. It is important to keep the insertion site clean and dry but if it becomes sore and swollen or there is excess discharge or oozing, you should let the staff at the hospital know at once. 

        2. Recovery process

Most people are usually able to go home on the same day or the next day after a PCI procedure, but you will be advised to arrange for someone to take you home.

The cardiology team will also advise you about cardiac rehabilitation, diet, activities, driving, and work and what to expect during recovery depending on how you are after the procedure.

Types of percutaneous coronary intervention

    Balloon angioplasty

This involves the expanding of the balloon that has been placed inside a coronary artery to help open the narrowing and to break down the plaque that has caused the narrowing or a blockage. However, it is no longer the main type of PCI procedure as it was found that the ballooned artery can sometimes be narrowed or blocked again (this is called stenotic state or Restenosis). But it can still be used if the other types of PCI are not suitable for you.³

    Stent placement

When a coronary stent is needed, a catheter carrying the stent (over the balloon used to expand the artery) is placed over the guidewire which is on the coronary artery site that is affected. Then the balloon is expanded, which in turn expands the stent and it is then deployed in the artery, thus, opening the narrowing. It is usually done by either of two methods,⁷ of which are:

      1. Bare-metal stents

These are-metal stents have been reported with an increased risk of causing the affected arteries to narrow again. This is suggested to be caused by the immune system attacking the stent thinking it’s a foreign body thereby causing swelling and unneeded tissue growth around the stent.

This is why Drug-eluting stents are now the preferred method of choice according to the National Institute for Health and Care Excellence (NICE).⁸

        2. Drug-eluting stents These are coated with medications that reduce the body’s abnormal  immune response. It is suggested to cause less risk compared to bare-metal stents.⁷

    Atherectomy

Coronary atherectomy is an invasive procedure that involves physically removing the plaque causing the blockage from the arteries by cutting the plaque directly with a cutter or using a laser. Atherectomy is typically followed by balloon angioplasty and stent placement.⁹ 

Risks and complications

It is important to note that all heart procedures usually come with a lot of risks. Some of the risks and possible complications that could happen after the procedure include¹⁰

• Bleeding
• Infection
• Allergic reactions
• Restenosis
• Emergency situations

Post-PCI care and lifestyle changes

    Medication management

According to some studies, the drugs used in drug-eluting stents can cause a delay in the healing of the coronary artery around where the stent has been placed.¹¹ This is why a blood-thinning treatment is recommended to be taken for one year after a PCI. Apparently, this helps to reduce the chances of developing a blood clot in the coronary artery which can lead to a heart attack. These medicines could include Aspirin and Clopidogrel or Prasugrel or Ticagrelor.¹¹

    Follow-up appointments

This usually involves a multidisciplinary team of GPs, cardiologists, nurse practitioners, specialist nurses and pharmacists, who all aim to offer you support and can address any concerns that you have post-procedure including your medications. The clinicians will usually give you a date for a follow-up appointment to check your progress.¹¹

    Adopting a heart-healthy lifestyle

Even after a PCI, it is important to keep a healthy lifestyle to reduce your risk of developing any future complications. These can include

        1. Diet modifications

Eating a healthy diet including fruits and vegetables, avoiding foods with high levels of fats and salt.

        2. Exercise recommendations

The hospital will usually recommend the type of activities you can do and which ones you need to avoid. But in general, it is recommended to avoid any strenuous exercises or heavy lifting for at least one week after the procedure or till your wounds heal.¹¹

Summary

Coronary Artery Disease (CAD) also known as coronary heart disease (CHD) is a heart condition characterised by the narrowing or blockage of the blood vessels of the coronary artery leading to reduced blood flow in the heart.

Percutaneous Coronary Intervention (PCI) also known as coronary angioplasty is a specific procedure used in the treatment of CAD. There are different types of PCI, but your doctor will refer you to a hospital cardiologist if a PCI is needed. You should ask your doctor to help you decide on a cardiologist to perform the procedure if you do decide to have one, the cardiology team will advise and discuss the plan and the procedure with you so that you are aware of what the procedure involves.

It is still important to adopt a heart-healthy lifestyle after a PCI to avoid any further damage to the heart or future problems.