Percutaneous Coronary Intervention Technique
- Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD more...
Coronary angiography and percutaneous coronary intervention (PCI) are more commonly performed via the femoral or the radial artery and less commonly performed via the brachial or ulnar artery. Overall, the femoral artery is the most common route of access for these procedures; however, the use of radial access is increasing.
Two randomized, controlled trials reported lower mortality with transradial access than with femoral access in ST-segment elevation myocardial infarction (STEMI) patients undergoing PCI. In the RIFLE STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study, a multicenter randomized trial involving 1001 STEMI patients, radial access was associated with significantly lower rates of cardiac mortality (5.2% vs 9.2%) and bleeding (7.8% vs 12.2%) than femoral access was.
The RIVAL (Radial Versus Femoral Access for Coronary Intervention) trial compared the efficacy and bleeding outcomes of radial and femoral access separately in patients with STEMI and non-STEMI (NSTEMI). Radial access was associated with reduced all-cause mortality (1.3% vs 3.2%) and reduced death/myocardial infarction (MI)/stroke (2.7% vs 4.6%) in STEMI patients but not in NSTEMI patients. In both STEMI and NSTEMI groups, radial access was associated with significantly reduced ACUITY major bleeding and major vascular access site complications.
The European Society of Cardiology guidelines on STEMI patients recommend preference of radial over femoral access, if performed by an experienced radial operator (class IIa, level B). The Society for Cardiovascular Angiography and Interventions released a consensus statement on best practices for the use of radial access for diagnosing and treating coronary artery disease (CAD), focusing on avoiding radial artery occlusion, reducing radiation exposure, and using the transradial approach in STEMI.
Recommendations for STEMI patients include the following:
Before integrating the radial approach into practice, clinicians should gain experience with at least 100 elective radial procedures and have a femoral crossover rate lower than 4%
Practitioners should start with easier cases and ensure that all laboratory personnel are comfortable with the procedure
A bailout approach to either contralateral radial or femoral access should be prepared in advance
The patient is prepared as described earlier (see Patient Preparation).
For transradial catheterization, an arteriotomy is made approximately 2 cm proximal to the radial styloid process so as to avoid the distal bifurcation and diminutive vessels. While palpation is being done, the radial artery is punctured with a micropuncture needle, and a hydrophilic sheath is placed by means of the modified Seldinger technique.
Once the sheath is in place, an intra-arterial vasodilator is given (nicardipine 500 µg or verapamil 5 mg), with half the dose administered at the beginning of the procedure and the other half at the end. Intravenous (IV) heparin dramatically reduces the risk of radial artery occlusion and is therefore often used in transradial catheterization (usual dose, 50 units/kg; maximum total dose, 5000 units).
For transfemoral catheterization, the arteriotomy site is the common femoral artery, above its bifurcation into the deep femoral artery (profunda femoris) and the superficial femoral artery and below the inferior epigastric artery. Because the skin crease can sometimes be misleading, a combination of various other anatomic landmarks may be used, such as bony landmarks (aiming 2 cm below the center of the inguinal ligament) and the point of maximal palpable impulse.
Fluoroscopy is often used to mark the femoral head, and the target zone for the arteriotomy is the middle of the femoral head. A micropuncture (21-gauge) or 18-gauge needle is used to puncture the femoral artery, and a sheath is placed with the modified Seldinger technique. Sheath size varies according to the preference of the operator; in general, it is in the range of 4-6 French.
Once access is obtained, catheters are advanced over a 0.035-in. J-tip guide wire into the ascending aorta. Various different catheter shapes are available; the choice depends on the operator’s preference and the patient’s anatomy. Selective coronary angiography is performed in different views (at least two orthogonal views for each segment of the coronary) using hand or power injections of iohexol.
Guide catheters have the same external diameter as diagnostic catheters but a larger lumen and are used for PCI. Once the catheter has engaged the coronary ostium and diagnostic angiograms have been obtained, weight-based IV anticoagulant (unfractionated heparin [UFH], bivalirudin, or low-molecular-weight heparin [LMWH]) therapy may be administered. If the patient is not on long-term dual antiplatelet therapy (DAPT), a loading dose of a P2Y12 inhibitor is also given. As noted above, all patients should have been pretreated with aspirin.
A 0.014-in. guide wire is then advanced into the coronary artery across the stenotic lesion. All balloon catheters and other devices will be tracked over this wire. In some cases, direct stenting of the lesion can be done; however, in most cases, vessel preparation with either predilation with a semicompliant balloon or an atherectomy device is performed. The balloon is then withdrawn, and a stent of appropriate length and diameter is advanced over the coronary guide wire, positioned across the lesion, and deployed.
Depending on the angiographic appearance of the stent, postdilation of the stent may or may not be performed with a noncompliant balloon. An intravascular imaging tool, such as intravascular ultrasonography (IVUS) or optical coherence tomography (OCT) (see Anatomic and Physiologic Assessment), can be used for further delineation and assessment of the anatomy including plaque burden, vessel size, and stent deployment.
After the PCI result is deemed adequate, the coronary wire is removed and final angiograms are taken.
Access sheath removal
In transradial catheterization, the sheath is removed immediately after the procedure, and a compression band is applied to the wrist. With a goal of patent hemostasis, this band is left inflated for 90-120 minutes and then gradually deflated.
In transfemoral catheterization, hemostasis is achieved either by the use of vascular closure devices (inserted at the end of the case) or by manual compression (a few hours later when activated clotting time [ACT] is in the appropriate range).
Anatomic and Physiologic Assessment
Although coronary angiography provides a display of luminal narrowing in multiple planes and is useful in guiding PCI, it provides only limited information about the vessel wall, which is where the atherosclerotic process resides.
IVUS (see the image below) was developed to provide information about the plaque, the vessel wall, and the degree of luminal narrowing. It provides a tomographic cross-section of the vessel, allowing operators to gather significant qualitative and quantitative information that is potentially valuable for assessing stenosis severity and determining the true extent of atherosclerotic involvement.
The lumen border and the media-adventitia interface are the key landmarks that should be identified during interrogation. Plaque can be distinguished from the lumen on the basis of differences in echogenicity. In addition to providing information about the amount and distribution of plaque, IVUS can identify features of plaque composition (eg, calcification and lipid collections) that may not be appreciated by angiography alone.
Frequent uses of IVUS include assessment of indeterminate lesions and evaluation of adequate stent deployment. The latter is particularly important, in that proper deployment of drug-eluting stents (DESs) is critical for reducing thrombosis rates. Developments in ultrasonography (eg, virtual histology) and other technologies (eg, OCT and plaque thermography) have led to ways of characterizing and identifying vulnerable segments of plaque that may pose a risk for future cardiac events.
Optical coherence tomography
OCT uses light-based imaging to capture micrometer-resolution images of the artery wall. It has 10 times higher resolution than IVUS does but is unable to penetrate as deep into the vessel wall. OCT’s high resolution enables it to better evaluate stent strut apposition and neointimal stent strut coverage.
Coronary physiologic assessment
Intracoronary Doppler pressure wires are used to characterize coronary lesion physiology and estimate lesion hemodynamic severity. Comparison of the pressure distal to a lesion with aortic pressure at maximal coronary hyperemia enables determination of fractional flow reserve (FFR) (see the image below).
An FFR measurement lower than 0.80 during maximal hyperemia (induced via administration of adenosine) is consistent with a hemodynamically significant lesion. This determination is useful in deciding whether to perform PCI in an angiographic intermediate lesion. Clinical data—namely, the findings from the DEFER (Deferral of Percutaneous Coronary Intervention) study—support using this approach; a low event rate was seen in medically managed patients with angina and an FFR measurement greater than 0.75.
The FAME (Fractional Flow Reserve versus Angiography for Guiding PCI in Patients with Multivessel Coronary Artery Disease) trial showed that routine measurement of FFR during angioplasty reduced the risk of death, MI, or repeat revascularization by 30% and the risk of death or MI by 35%, compared with the current practice of using angiography to guide stenting decisions.
In this study, a cutoff FFR value of 0.80 was used to define a nonischemic lesion. A 2-year follow-up of the FAME trial showed continuing significant reductions in the combined endpoint of death and MI with the use of FFR in comparison with standard angiography-guided PCI.
The FAME 2 trial randomly assigned patients with stable CAD who had at least one stenosis with an FFR less than 0.8 to receive either FFR-guided PCI plus optimal medical therapy or optimal medical therapy alone. The occurrence of the primary endpoint—a composite of any-cause mortality, nonfatal MI, or urgent revascularization within 2 years—was significantly lower in the PCI group than in the medical therapy group (8.1% vs 19.5%).
However, it is important to note that this difference in primary endpoint was primarily driven by a reduction in the rate of urgent revascularization in the PCI group (4% vs 16.3); there were no significant between-group differences in mortality and MI rate.
The FAME 3 study, currently under way, is a multinational multicenter trial designed to compare FFR-guided PCI (using second-generation DESs) with coronary artery bypass grafting (CABG) in patients with multivessel CAD.
Currently, the use of FFR is recommended to assess the hemodynamic significance of angiographically intermediate (40-70%) stenosis. Both FFR and IVUS have shown favorable outcomes when used to assess angiographically intermediate lesions; however, the data on FFR are more robust.
Adjunctive Therapies in Catheterization Laboratory
Aspirin and heparin have been the traditional adjunctive medical therapies for patients undergoing coronary angioplasty and have been shown to decrease complications after the procedure. Since 1994, several antithrombotic drugs have been developed that have advantages over standard heparin. Although heparin is an effective anticoagulant, it has several limitations, including variable pharmacokinetics requiring careful monitoring, inhibition by substances released from activated platelets, and inability to inhibit fibrin-bound thrombin.
To address these limitations, several direct thrombin inhibitors have been developed. Hirudin and bivalirudin were evaluated in multicenter trials,[24, 81, 82, 83] and both agents were found to be slightly better than heparin in preventing ischemic complications during balloon angioplasty, though they had no effect on restenosis rates.
At some centers, LMWHs are being substituted for standard heparin in the treatment of patients with acute coronary syndrome (ACS) and during coronary interventions. Factor IX and factor Xa inhibitors are being evaluated as potential alternative anticoagulants; however, trials have failed to show a significant difference in efficacy of factor Xa inhibition between these agents and UFH.
In the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial, 3602 patients presenting with STEMI and undergoing PCI were treated with bivalirudin and had substantially lower 30-day rates of major hemorrhagic complications and lower rates of net adverse clinical events (ie, major bleeding or composite major adverse cardiovascular events [death, reinfarction, target-vessel revascularization for ischemia, or stroke]) than patients treated with heparin plus a glycoprotein (GP) IIb/IIIa inhibitor.
The investigators continued to follow patients for 1 year. Data were available for 1696 patients in the bivalirudin group and 1702 patients in the heparin plus GPIIb/IIIa inhibitor group. At 1 year, the bivalirudin group continued to have reduced rates for major bleeding and adverse events as compared with the heparin plus GPIIb/IIIa inhibitor group. Death, reinfarction, target-vessel revascularization for ischemia, and stroke rates were similar in the two groups.
The Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial, which studied the impact of age on outcomes in moderate- and high-risk non–ST-segment elevation ACS (NSTE-ACS), found that patients aged 75 years or older who were treated with bivalirudin alone had similar ischemic outcomes but significantly lower bleeding rates as compared with those who were treated with heparin plus GPIIb/IIIa inhibitors, both overall and in the PCI subset.
In this trial, outcomes were analyzed at 30 days and at 1 year in four age groups, overall, and in those undergoing PCI. Of the 13,819 patients studied, 3655 (26.4%) were younger than 55 years, 3940 (28.5%) were aged 55-64 years, 3783 (27.4%) were aged 65-74 years, and 2441 (17.7%) were 75 years or older. Older patients had more cardiovascular risk factors and had a higher acuity at presentation.
In the NAPLES (Novel Approaches for Preventing or Limiting Events) trial, Tavano et al compared bivalirudin with UFH plus a GPIIb/IIIa inhibitor (ie, tirofiban) during PCI in 335 patients with diabetes mellitus and concluded that elective PCI with bivalirudin monotherapy is safe and feasible in patients with diabetes.
The bivalirudin group experienced significantly less in-hospital bleeding (8.4% vs 20.8%). Non–Q-wave MI rates were similar in the two groups (10.2% for bivalirudin vs 12.5% for UFH-tirofiban. In the early days of stenting, multiple antiplatelet agents and warfarin were used in an attempt to prevent stent thrombosis, but thrombosis continued to occur in approximately 6% of patients.
The EUROMAX (European Ambulance Acute Coronary Syndrome Angiography) trial randomly assigned 2218 STEMI patients to receive either bivalirudin or UFH or LMWH with optional GP IIb/IIIa inhibitors. The bivalirudin group had a lower risk of the primary outcome, which was a composite of death or major bleeding not associated with CABG (5.1% vs 8.5%). It also had a lower rate of the principal secondary outcome, a composite of death, reinfarction, or non-CABG major bleeding (6.6% vs 9.2%).
These differences reported in the EUROMAX trial were primarily driven by a reduced risk of major bleeding (2.6% vs 6%); there were no significant differences in the rates of death or reinfarction. The bivalirudin group had higher rates of acute stent thrombosis (1.1% vs 0.2%).
The single-center HEAT PPCI (How Effective Are Antithrombotic Therapies in Primary PCI) trial randomly assigned 1812 STEMI patients to receive either bivalirudin or UFH and compared the two regimens with respect to primary efficacy outcome (composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target-lesion revascularization) and primary safety outcome (incidence of major bleeding).
In this trial, heparin reduced the incidence of major adverse ischemic events as compared with bivalirudin (5.7% for heparin vs 8.7% for bivalirudin). There was no increase in the rate of bleeding complications with heparin (3.5% vs 3.1% for bivalirudin).The results of the HEAT PPCI trial differed from those of previous trials and suggested that bleeding risk is not increased with heparin. These results will have to be replicated before a conclusive decision is made on the safest and most effective approach to anticoagulation during PCI.
In summary, several trials have shown lower bleeding with bivalirudin than with heparin with or without GPIIb/IIIa inhibitors. However, some of these trials involved frequent use of GPIIb/IIIa inhibitors, which is no longer a routine strategy but is reserved for use as a bailout measure or when thrombus burden is high or P2Y12 inhibitor loading is inadequate. Some of the bleeding results can thus be attributed to GPIIb/III inhibitor use.
The HEAT PPCI results were in favor of heparin, and the significant cost difference between heparin and bivalirudin (heparin is substantially cheaper) has once again raised interest in heparin as the anticoagulant for PCI. One limitation of HEAT PPCI, however, was that it was a single-center trial; therefore, data from currently ongoing large multicenter trials addressing this question are needed to address this issue definitively.
The most feared complication of intracoronary stents has been thrombotic occlusion of a freshly deployed metallic endoprosthesis. Aggressive antiplatelet therapy has been shown to significantly reduce the risk of stent thrombosis and is required in all patients receiving a stent.
Patients receiving stents are now treated with a combination of aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor, or cangrelor); with this DAPT, the development of less thrombogenic stents and improvements in stent deployment technology, the incidence of subacute thrombosis currently is approximately 1%.
Today, DAPT is provided to all stent patients for a minimum of 4 weeks after a bare-metal stent is placed and for a minimum of 12 months when a DES is used. Several trials have suggested that a shorter duration of P2Y12 inhibitor administration may be safe in patients with second-generation DESs, but the guidelines still recommend 12 months of DAPT.
Issues remain as to whether the duration of aspirin and P2Y12 inhibitor therapy should be longer in patients who received first-generation DESs. In the authors’ view, aspirin therapy with a baby aspirin should be maintained for life in all DES patients, and lifetime P2Y12 inhibitor therapy should be considered unless bleeding contraindications restrict its use. Currently, there are multiple ongoing studies designed to evaluate the question of optimal DAPT duration for second-generation DESs.
In elective situations, clopidogrel is most effective when given before PCI; prasugrel and ticagrelor have been studied in patients with ACS but not in stable patients. In acute situations, this approach may not be practical, and thus, the P2Y12 inhibitor is often given after PCI.
Concerns still exist regarding the risk of bleeding and platelet transfusion requirements in patients taking a P2Y12 inhibitor who require urgent CABG. Because emergency CABG is rare, there may be time to risk-stratify patients and to give a P2Y12 inhibitor before cardiac catheterization. If CABG is required, the effect of a P2Y12 inhibitor usually diminishes within 5 days.
Another important consideration is the clopidogrel loading dose. American College of Cardiology (ACC)/American Heart Association (AHA) guidelines recommend giving 600 mg within the 6 hours preceding PCI with stenting.
Results of the HORIZONS-AMI study also indicated that a 600-mg loading dose of clopidogrel yielded better clinical outcomes than a 300-mg dose. The 2158 patients in the 600-mg group had significantly lower unadjusted 30-day mortality than the 1153 in the 300-mg group (1.9% vs 3.1%), as well as lower rates of reinfarction (1.3% vs 2.3%) and stent thrombosis (1.7% vs 2.8%). Bleeding rates did not differ. Similar differences were shown in patients who received either bivalirudin or UFH plus a GP inhibitor.
The GRAVITAS (Gauging Responsiveness with A VerifyNow Assay—Impact on Thrombosis And Safety) study, which enrolled 2214 patients with high on-treatment reactivity 12-24 hours after PCI, found that high-dose clopidogrel (600 mg initially, 150 mg/day thereafter) provided a 22% absolute reduction in the rate of high on-treatment reactivity at 30 days in comparison with standard treatment (no additional loading dose, 75 mg/day).
However, the GRAVITAS investigators noted no difference in the primary endpoint of 6-month incidence of death from cardiovascular causes, nonfatal MI, or stent thrombosis. Severe or moderate bleeding according to the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) definition was lower in the standard group, but the decrease did not reach statistical significance.
Use of newer intravenous (IV) antiplatelet agents such as cangrelor may help overcome these issues. In June 2015, cangrelor was approved by the US Food and Drug Administration (FDA) for use in adults undergoing PCI. Aspirin 325 mg should be given before all PCIs and then maintained at a dosage of 81 mg/day.
Clopidogrel is the most frequently utilized P2Y12 inhibitor. Numerous studies have shown the inconsistency in the metabolism of this drug as a result of variations in the CYP2C19 pathway. Clopidogrel is a prodrug that is metabolized to an active form by the cytochrome (CYP) 450 enzyme system in the liver. Research has demonstrated that genetic variation at the CYP450 2C19 locus results in decreased metabolic activation of clopidogrel and increased risk of stent thrombosis and ischemic events.
This finding led to an update to the package insert for clopidogrel, which now includes a “black box” warning for use in patients who are “poor metabolizers” (ie, those who have two abnormal alleles at the CYP 2C19 locus; approximately 2-4% of white patients fall into this category).
Individuals with a single abnormal allele have intermediate metabolism of clopidogrel to the active metabolite. In a meta-analysis of nine studies and almost 10,000 patients, Mega et al found that the presence of even one reduced-function CYP2C19 allele in patients treated with clopidogrel after PCI was associated with a significantly increased risk of major adverse cardiovascular events (MACE), particularly stent thrombosis.
Studies of platelet function testing have shown variability in the pharmacodynamic response to clopidogrel, and studies of genetic testing have identified genetic polymorphisms that affect its absorption (ABCB1), metabolism (eg, CYP2C19) and ultimately its pharmacodynamic effects. Genetic testing for CYP2C19 polymorphisms has potentially important prognostic implications.
In population-based studies, patients with high on-treatment platelet reactivity have had an increased risk of MACE. Unfortunately, studies have not shown that measuring platelet reactivity in an individual patient (primarily with the VerifyNow assay) is useful for identifying those at risk. Currently, measurement of platelet reactivity is still reserved for use as a research tool.[92, 93]
Besides genetic polymorphisms, there are clinical factors to consider, such as obesity and diabetes mellitus, as well as potential drug interactions, such as those with calcium-channel blockers and proton pump inhibitors (PPIs). In particular, omeprazole was implicated in clopidogrel hyporesponsiveness. However, the COGENT trial demonstrated that there was no increase in MACE in patients who took clopidogrel plus a PPI as compared with clopidogrel alone.
Prasugrel is a thienopyridine adenosine diphosphate (ADP) receptor inhibitor that inhibits platelet aggregation. It has been shown to reduce new and recurrent MIs. The loading dose is 60 mg orally given once, and the maintenance dosage is 10 mg/day orally (given with aspirin 75-325 mg/day).
Prasugrel is indicated for reducing thrombotic cardiovascular events (including stent thrombosis) in patients with an ACS that is managed with PCI. It is used specifically for unstable angina or NSTEMI or for acute STEMI that is managed with primary or delayed PCI.
TRITON TIMI (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel—Thrombolysis in Myocardial Infarction) 38 analyzed whether the type, size, and timing of MI affected prasugrel’s ability to reduce new or recurrent MI. Compared with clopidogrel, prasugrel significantly reduced the overall risk of any type of MI (eg, procedure-related, nonprocedural, and consistently across MI size). Significant, sometimes fatal, bleeding occurred more often with prasugrel than with clopidogrel.
Ticagrelor, a cyclopentyl-triazolo-pyrimidine, is an oral P2Y12 receptor antagonist that reversibly inhibits platelets. It does not require hepatic bioactivation, because it is an active drug. The PLATO (Platelet Inhibition and Patient Outcomes) trial, looking at 18,264 patients with ACS (35% STEMI), showed that ticagrelor reduced the composite primary efficacy event (death, MI, or stroke) in comparison with clopidogrel (9.8% vs 11.7%) but increased non–CABG-related major bleeding (2.8% vs 2.2%) and fatal intracranial hemorrhage.
Potential disadvantages of ticagrelor include side effects such as dyspnea, ventricular pauses, significantly greater cost than generic clopidogrel, and increased concentration of uric acid and creatinine.
On the basis of the benefit observed in these trials, current NSTE-ACS guidelines state that it is reasonable to use ticagrelor in preference to clopidogrel for DAPT in patients with NSTE-ACS who undergo an early invasive or ischemia-guided strategy. Prasugrel (at the time of PCI) may be chosen over clopidogrel for DAPT in patients with NSTE-ACS who undergo PCI and are not at high risk for bleeding complications.
Glycoprotein inhibitor therapy
PCI results in disruption of the coronary endothelium, which leads to platelet activation. Activated platelets bind to the vessel wall (adhesion) and to each other (aggregation) and release numerous vasoactive compounds.
Aspirin blocks the cyclooxygenase pathway and reduces thrombotic complications after balloon angioplasty. However, despite heparin and aspirin therapy, thrombotic complications are not eliminated. Studies identified the importance of the GPIIb/IIIa receptor, which binds fibrinogen and mediates platelet cross-linking and aggregation. The introduction of GP IIb/IIIa inhibitors had a major influence on PCI treatment strategies in the 1990s, but these drugs are now used much less frequently than they once were.
Early studies of GPIIb/IIIa inhibitors showed the following:
Abciximab, tirofiban, and eptifibatide are capable of reducing ischemic complications in patients undergoing balloon angioplasty and coronary stenting
In primary PCI, GPIIb/IIIa inhibitors can improve flow and perfusion and reduce adverse events
Abciximab may improve outcomes in patients when given before arrival in the catheterization laboratory for primary PCI 
A meta-analysis of GPIIb/IIIa inhibitor trials showed a significant reduction in early mortality when these agents are used during coronary intervention; the combined endpoint of death or MI was also reduced significantly at 30 days
The EVA-AMI (Eptifibatide vs Abciximab in Primary PCI for Acute ST Elevation Myocardial Infarction) trial, which compared the efficacy of two GPIIb/IIIa inhibitors as adjuncts to PCI in 427 patients with STEMI, showed that double-bolus eptifibatide followed by a 24-hour infusion was as effective as single-bolus abciximab followed by a 12-hour infusion for ST-segment resolution 
These agents are effective at reducing ischemic complications of PCI; however, they have not been shown to improve outcome in saphenous vein graft PCI
A meta-analysis of 22 studies including 10,123 patients evaluated the use of GPIIb/IIIa inhibitors during elective PCI in patients pretreated with clopidogrel determined that GPIIb/IIIa inhibitors had no effect on mortality or major bleeding but were associated with a decrease in the incidence of nonfatal MI and an increase in the rate of minor bleeding 
The evidence supporting the use of GPIIb/IIIa inhibitors derives largely from a the time before the use of oral P2Y12 inhibitors. Several studies have failed to show a benefit with upstream administration of GPIIb/IIIa inhibitors. In view of these findings, coupled with the increased risk of bleeding, routine use of these agents is no longer recommended. GPIIb/IIIa inhibitors may be used as an adjunctive therapy at the time of PCI, on an individual basis, for large thrombus burden or inadequate P2Y12 receptor antagonist loading.
The common complications of PCI are bleeding, hematoma, and pseudoaneurysm at the access site. To minimize the risk of these complications, extreme care must be taken in obtaining access at the beginning of the procedure.
Bleeding avoidance strategies (eg, vascular closure devices, bivalirudin, the radial approach, and combinations thereof) appear to lower the risk of post-PCI bleeding for both men and women; however, such strategies may be of particular significance in female patients, in that the absolute differences in risk are substantially greater in women.
A retrospective cohort analysis of data on 2,820,874 PCI procedures from the CathPCI registry demonstrated that the use of radial access for PCI (r-PCI) was on the increase and that the procedure was associated with a lower risk of bleeding and vascular complications than traditional transfemoral PCI, even after age, sex, and clinical presentation were accounted for.
Anaphylaxis caused by the contrast agent can occur; therefore, a careful preprocedural history must be obtained. Patients with a prior anaphylactoid reaction to the contrast media should receive appropriate steroid prophylaxis before repeat contrast administration. Contrast administration is one of the leading causes of hospital-acquired acute kidney injury (AKI). The only strategies that have been shown to minimize the risk of AKI are hydration and minimizing the use of contrast.
Early registries of balloon angioplasty results showed complication rates that were much higher than those typically observed today. Reductions in the complication rate have been complemented by improvements in the acute success rate. Previously, registries such as the National Heart, Lung, and Blood Institute (NHLBI) Coronary Angioplasty Registry reported primary success rates of 61%. Today, with the use of stents and adjunctive pharmacotherapy, success rates range from 95% to 99%.
The mechanism by which balloon angioplasty or stenting improves luminal diameter is associated with significant local trauma to the vessel wall, which can, in turn, lead to occlusive complications in a minority of patients. Coronary artery dissection typically results from the vessel injury secondary to balloon expansion. Animal and postmortem human studies have shown that localized dissection at the site of balloon expansion is detected angiographically in as many as 50% of patients immediately after the procedure.
Such small dissections probably are necessary to obtain adequate lumen expansion; they rarely interfere with antegrade blood flow and are usually unimportant. Angiographic follow-up typically shows no residual evidence of a dissection as early as 6 weeks after angioplasty in most of the cases studied. However, larger dissections can lead to complications.
Often, these dissections are treated with a stent to cover the dissection flap. Coronary perforation or rupture is very rare (occurring in fewer than 1% of cases) and is typically associated with the use of ablative devices or oversized balloons. It can occur from the wire tip or at the culprit lesion. Wire perforations are typically small and usually do not warrant further intervention; perforations from balloon inflation or stent implantation can occasionally necessitate treatment with a covered stent graft.
Abrupt vessel closure may occur in as many as 5% of balloon angioplasty cases, usually developing when the true lumen is compressed by a large dissection flap, 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 fivefold increase in the risk of abrupt closure. This underscores the importance of a good postprocedural angiographic result for ensuring good clinical outcomes.
Since the introduction and implementation of intracoronary stents and newer antiplatelet drugs, the incidence of abrupt closure has decreased significantly, to less than 1%. Microembolization of plaque debris or adherent thrombus may also cause acute complications during angioplasty and may contribute to postprocedural cardiac enzyme elevation and chest pain in some patients.
In fewer than 1% of angioplasty patients, microembolization of the platelet-rich thrombus may cause diffuse distal arteriolar vasospasm secondary to release of vasoactive agents, resulting in no-reflow. This complication is difficult to treat but may respond to intracoronary calcium channel antagonists, adenosine, or nitroprusside. Patients undergoing balloon angioplasty of saphenous vein graft lesions and primary angioplasty in the setting of acute MI with a large amount of adherent thrombus are at greatest risk for distal embolization.
Restenosis (see below) after balloon angioplasty necessitating a second revascularization procedure is a major limitation that occurs in about 15-30% of patients, depending on the definition of restenosis applied. With the advent of DESs, restenosis rates have fallen to less than 10%.
Some of the very rare but serious complications of PCI are stroke, MI, and death. With advances in technique, technology, and adjuvant medical therapy, PCI is now associated with mortality and emergency bypass rates lower than 1%. The rate of nonfatal MI after coronary angioplasty ranges from 5% to 15%, whereas the rate after stent placement ranges from 2% to 5%.
After balloon angioplasty or stent implantation, the vessel wall undergoes a number of changes. Platelets and fibrin adhere to the site within minutes of vessel injury. Within hours to days, inflammatory cells infiltrate the site, and vascular smooth muscle cells begin to migrate toward the lumen.
The vascular smooth muscle cells then undergo hypertrophy and excrete an extensive extracellular matrix. During this period of vascular smooth muscle cell proliferation, endothelial cells colonize the surface of the lumen and regain their normal function.
Over the course of several weeks to months, multiple forces interact to cause remodeling of the vessel wall with either a decrease in lumen diameter (negative remodeling) or an increase in lumen diameter (positive remodeling). The amount of late loss in lumen diameter is dependent on the amount of neointimal proliferation and the degree of remodeling after intervention (see the image below). After 6 months, the repair process stabilizes and the risk of restenosis decreases significantly.
Several studies have shown that the lumen diameter or area after treatment is one of the major predictors of restenosis. The use of coronary artery stents has decreased the rate of restenosis by improving the acute gain achieved and by minimizing negative remodeling.
Depending on the definition used, angiographic restenosis has been reported in as many as 50% of patients within 6 months after balloon angioplasty, necessitating repeat target-vessel revascularization in approximately 20-30% of patients. As noted (see above), DESs have reduced restenosis rates to less than 10%. Poststenting lumen diameter and lesion complexity are still the major predictors of restenosis with these newer stents.
Although DESs have significantly reduced the incidence of restenosis, they are still linked with concerns regarding stent thrombosis. In fact, the thrombosis rate for a DES is virtually identical to that for a bare-metal stent at 1 year (0.5-0.7%). However, late stent thrombosis (>1 year) continues to occur with DESs, whereas it is exceedingly rare with bare-metal stents.
The factor that makes the greatest contribution to stent thrombosis is interruption of antiplatelet therapy. Current guidelines recommend a minimum of 1 year of DAPT for patients with DESs and a month for those with bare-metal stents. DESs take longer to endothelialize on the coronary vessel wall than bare-metal stents do, and discontinuing DAPT may expose patients to an increased risk for stent thrombosis over time.
In some clinical situations (eg, before urgent noncardiac surgery in which antiplatelet therapy may have to be discontinued and when known or potential medicine compliance issues are present), implanting a bare-metal stent during PCI may be preferred to implanting a DES. Another important factor is final stent diameter and area.
Underdeployment or incomplete apposition of the DES may also increase the risk of stent thrombosis. This is not to say that DESs are unsafe. In fact, there is no difference in long-term rates of death and MI between DESs and bare-metal stents; however, there is a striking reduction in restenosis.
Stone et al found that although stent thrombosis is infrequent, it results in higher rates of MI and death. The greater frequency of target-vessel revascularization results in a lower rate of MI and death. Although late stent thrombosis is a risk with DESs, the noticeable reduction in restenosis may offset the risk.
An analysis of data from 7090 consecutive PCI-treated patients in the ISAR-ASPI (Intracoronary Stenting and Antithrombotic Regimen-ASpirin and Platelet Inhibition) registry suggested that high platelet reactivity in patients on aspirin (HAPR) at the time of PCI was associated with a greater risk of death or stent thrombosis (6.2% vs 3.7% for non-HAPR) during the first year after PCI. Moreover, HAPR independently predicted death or stent thrombosis at 1 year. These findings may support use of HAPR as a prognostic biomarker in PCI-treated patients.
O’Riordan M. Continuous, independent relationship with FFR and outcomes, modulated by treatment. Medscape Medical News [serial online]. [Full Text].
Johnson NP, Tóth GG, Lai D, et al. Prognostic value of fractional flow reserve: linking physiologic severity to clinical outcomes. J Am Coll Cardiol. Oct 21 2014. 64(16):1641-54. [Medline].
Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Jr., Ganiats TG, et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014. [Medline].
O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Jr., Chung MK, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013. 127(4):e362-425. [Medline].
Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Circulation. 2011. 124(23):e574-651. [Medline].
Coronary Revascularization Writing G, Patel MR, Dehmer GJ, Hirshfeld JW, Smith PK, Spertus JA, et al. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Thorac Cardiovasc Surg. 2012. 143(4):780-803. [Medline].
Rao SV, Kaltenbach LA, Weintraub WS, Roe MT, Brindis RG, Rumsfeld JS, et al. Prevalence and outcomes of same-day discharge after elective percutaneous coronary intervention among older patients. JAMA. 2011. 306(13):1461-7. [Medline].
Abdelaal E, Rao SV, Gilchrist IC, Bernat I, Shroff A, Caputo R, et al. Same-day discharge compared with overnight hospitalization after uncomplicated percutaneous coronary intervention: a systematic review and meta-analysis. JACC Cardiovasc Intervent. 2013. 6(2):99-112. [Medline].
Brayton KM, Patel VG, Stave C, de Lemos JA, Kumbhani DJ. Same-day discharge after percutaneous coronary intervention: a meta-analysis. J Am Coll Cardiol. 2013. 62(4):275-85. [Medline].
Fox KA, Poole-Wilson P, Clayton TC, Henderson RA, Shaw TR, Wheatley DJ, et al. 5-year outcome of an interventional strategy in non-ST-elevation acute coronary syndrome: the British Heart Foundation RITA 3 randomised trial. Lancet. 2005. 366(9489):914-20. [Medline].
Fox KA, Poole-Wilson PA, Henderson RA, Clayton TC, Chamberlain DA, Shaw TR, et al. Interventional versus conservative treatment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Randomized Intervention Trial of unstable Angina. Lancet. 2002. 360(9335):743-51. [Medline].
Parisi AF, Folland ED, Hartigan P. A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators. N Engl J Med. 1992. 326(1):10-6. [Medline].
Coronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trialCoronary angioplasty versus medical therapy for angina: the second Randomised Intervention Treatment of Angina (RITA-2) trial. Lancet. 1997. 350(9076):461-8. [Medline].
Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM, et al. Aggressive lipid-lowering therapy compared with angioplasty in stable coronary artery disease. Atorvastatin versus Revascularization Treatment Investigators. N Engl J Med. 1999. 341(2):70-6. [Medline].
Teo KK, Sedlis SP, Boden WE, O’Rourke RA, Maron DJ, Hartigan PM, et al. Optimal medical therapy with or without percutaneous coronary intervention in older patients with stable coronary disease: a pre-specified subset analysis of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive druG Evaluation) trial. J Am Coll Cardiol. 2009. 54(14):1303-8. [Medline].
Hueb W, Soares PR, Gersh BJ, Cesar LA, Luz PL, Puig LB, et al. The medicine, angioplasty, or surgery study (MASS-II): a randomized, controlled clinical trial of three therapeutic strategies for multivessel coronary artery disease: one-year results. J Am Coll Cardiol. 2004. 43(10):1743-51. [Medline].
Hueb WA, Soares PR, Almeida De Oliveira S, Arie S, Cardoso RH, Wajsbrot DB, et al. Five-year follow-op of the medicine, angioplasty, or surgery study (MASS): A prospective, randomized trial of medical therapy, balloon angioplasty, or bypass surgery for single proximal left anterior descending coronary artery stenosis. Circulation. 1999. 100(19 Suppl):II107-13. [Medline].
Stone GW, Lansky AJ, Pocock SJ, Gersh BJ, Dangas G, Wong SC, et al. Paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med. 2009. 360(19):1946-59. [Medline].
Henderson RA, Pocock SJ, Sharp SJ, Nanchahal K, Sculpher MJ, Buxton MJ, et al. Long-term results of RITA-1 trial: clinical and cost comparisons of coronary angioplasty and coronary-artery bypass grafting. Randomised Intervention Treatment of Angina. Lancet. 1998. 352(9138):1419-25. [Medline].
Henderson RA, Pocock SJ, Clayton TC, Knight R, Fox KA, Julian DG, et al. Seven-year outcome in the RITA-2 trial: coronary angioplasty versus medical therapy. J Am Coll Cardiol. 2003. 42(7):1161-70. [Medline].
Alderman EL, Kip KE, Whitlow PL, Bashore T, Fortin D, Bourassa MG, et al. Native coronary disease progression exceeds failed revascularization as cause of angina after five years in the Bypass Angioplasty Revascularization Investigation (BARI). J Am Coll Cardiol. 2004. 44(4):766-74. [Medline].
Pocock SJ, Henderson RA, Rickards AF, Hampton JR, King SB, 3rd, et al. Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery. Lancet. 1995. 346(8984):1184-9. [Medline].
Rodriguez A, Boullon F, Perez-Balino N, Paviotti C, Liprandi MI, Palacios IF. Argentine randomized trial of percutaneous transluminal coronary angioplasty versus coronary artery bypass surgery in multivessel disease (ERACI): in-hospital results and 1-year follow-up. ERACI Group. J Am Coll Cardiol. 1993. 22(4):1060-7. [Medline].
Stone GW, McLaurin BT, Cox DA, Bertrand ME, Lincoff AM, Moses JW, et al. Bivalirudin for patients with acute coronary syndromes. N Engl J Med. 2006. 355(21):2203-16. [Medline].
Hlatky MA, Boothroyd DB, Bravata DM, Boersma E, Booth J, Brooks MM, et al. Coronary artery bypass surgery compared with percutaneous coronary interventions for multivessel disease: a collaborative analysis of individual patient data from ten randomised trials. Lancet. 2009. 373(9670):1190-7. [Medline].
Serruys PW, de Jaegere P, Kiemeneij F, Macaya C, Rutsch W, Heyndrickx G, et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. Benestent Study Group. N Engl J Med. 1994. 331(8):489-95. [Medline].
Fischman DL, Leon MB, Baim DS, Schatz RA, Savage MP, Penn I, et al. A randomized comparison of coronary-stent placement and balloon angioplasty in the treatment of coronary artery disease. Stent Restenosis Study Investigators. N Engl J Med. 1994. 331(8):496-501. [Medline].
Serruys PW, Ong AT, van Herwerden LA, Sousa JE, Jatene A, Bonnier JJ, et al. Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial. J Am Coll Cardiol. 2005. 46(4):575-81. [Medline].
So SI. Coronary artery bypass surgery versus percutaneous coronary intervention with stent implantation in patients with multivessel coronary artery disease (the Stent or Surgery trial): a randomised controlled trial. Lancet. 2002. 360(9338):965-70. [Medline].
Rodriguez AE, Baldi J, Fernandez Pereira C, Navia J, Rodriguez Alemparte M, Delacasa A, et al. Five-year follow-up of the Argentine randomized trial of coronary angioplasty with stenting versus coronary bypass surgery in patients with multiple vessel disease (ERACI II). J Am Coll Cardiol. 2005. 46(4):582-8. [Medline].
Hannan EL, Racz MJ, Walford G, Jones RH, Ryan TJ, Bennett E, et al. Long-term outcomes of coronary-artery bypass grafting versus stent implantation. N Engl J Med. 2005. 352(21):2174-83. [Medline].
Serruys PW, Lemos PA, van Hout BA, Arterial Revascularisation Therapies Study part IISC, Investigators. Sirolimus eluting stent implantation for patients with multivessel disease: rationale for the Arterial Revascularisation Therapies Study part II (ARTS II). Heart. 2004. 90(9):995-8. [Medline].
Head SJ, Davierwala PM, Serruys PW, Redwood SR, Colombo A, Mack MJ, et al. Coronary artery bypass grafting vs. percutaneous coronary intervention for patients with three-vessel disease: final five-year follow-up of the SYNTAX trial. Eur Heart J. 2014. 35(40):2821-30. [Medline].
Group BDS, Frye RL, August P, Brooks MM, Hardison RM, Kelsey SF, et al. A randomized trial of therapies for type 2 diabetes and coronary artery disease. N Engl J Med. 2009. 360(24):2503-15. [Medline].
Dagenais GR, Lu J, Faxon DP, Kent K, Lago RM, Lezama C, et al. Effects of optimal medical treatment with or without coronary revascularization on angina and subsequent revascularizations in patients with type 2 diabetes mellitus and stable ischemic heart disease. Circulation. 2011. 123(14):1492-500. [Medline].
Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012. 367(25):2375-84. [Medline].
Verma S, Farkouh ME, Yanagawa B, Fitchett DH, Ahsan MR, Ruel M, et al. Comparison of coronary artery bypass surgery and percutaneous coronary intervention in patients with diabetes: a meta-analysis of randomised controlled trials. Lancet Diabetes Endocrinol. 2013. 1(4):317-28. [Medline].
Boden WE, O’Rourke RA, Crawford MH, Blaustein AS, Deedwania PC, Zoble RG, et al. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med. 1998. 338(25):1785-92. [Medline].
Anderson HV, Cannon CP, Stone PH, Williams DO, McCabe CH, Knatterud GL, et al. One-year results of the Thrombolysis in Myocardial Infarction (TIMI) IIIB clinical trial. A randomized comparison of tissue-type plasminogen activator versus placebo and early invasive versus early conservative strategies in unstable angina and non-Q wave myocardial infarction. J Am Coll Cardiol. 1995. 26(7):1643-50. [Medline].
Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators. Lancet. 1999. 354(9180):708-15. [Medline].
Poole-Wilson PA, Pocock SJ, Fox KA, Henderson RA, Wheatley DJ, Chamberlain DA, et al. Interventional versus conservative treatment in acute non-ST elevation coronary syndrome: time course of patient management and disease events over one year in the RITA 3 trial. Heart. 2006. 92(10):1473-9. [Medline].
Luciardi H, Muntaner J, Berman S, de la Serna F, Costantini C. [Acute coronary syndromes without ST segment elevation. Why should we take an interventionist approach?]. Arch Cardiol Mex. 2001. 71(4):295-305. [Medline].
Hirsch A, Windhausen F, Tijssen JG, Oude Ophuis AJ, van der Giessen WJ, van der Zee PM, et al. Diverging associations of an intended early invasive strategy compared with actual revascularization, and outcome in patients with non-ST-segment elevation acute coronary syndrome: the problem of treatment selection bias. Eur Heart J. 2009. 30(6):645-54. [Medline].
Mehta SR, Cannon CP, Fox KA, Wallentin L, Boden WE, Spacek R, et al. Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA. 2005. 293(23):2908-17. [Medline].
Fox KA, Clayton TC, Damman P, Pocock SJ, de Winter RJ, Tijssen JG, et al. Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data. J Am Coll Cardiol. 2010. 55(22):2435-45. [Medline].
Mehta SR, Granger CB, Boden WE, Steg PG, Bassand JP, Faxon DP, et al. Early versus delayed invasive intervention in acute coronary syndromes. N Engl J Med. 2009. 360(21):2165-75. [Medline].
Katritsis DG, Siontis GC, Kastrati A, van’t Hof AW, Neumann FJ, Siontis KC, et al. Optimal timing of coronary angiography and potential intervention in non-ST-elevation acute coronary syndromes. Eur Heart J. 2011. 32(1):32-40. [Medline].
Navarese EP, Gurbel PA, Andreotti F, Tantry U, Jeong YH, Kozinski M, et al. Optimal timing of coronary invasive strategy in non-ST-segment elevation acute coronary syndromes: a systematic review and meta-analysis. Ann Intern Med. 2013. 158(4):261-70. [Medline].
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. Lancet. 2003. 361(9351):13-20. [Medline].
Rathore SS, Curtis JP, Chen J, Wang Y, Nallamothu BK, Epstein AJ, et al. Association of door-to-balloon time and mortality in patients admitted to hospital with ST elevation myocardial infarction: national cohort study. BMJ. 2009. 338:b1807. [Medline].
Brodie BR, Gersh BJ, Stuckey T, Witzenbichler B, Guagliumi G, Peruga JZ, et al. When is door-to-balloon time critical? Analysis from the HORIZONS-AMI (Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction) and CADILLAC (Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications) trials. J Am Coll Cardiol. 2010. 56(5):407-13. [Medline].
Hochman JS, Lamas GA, Buller CE, Dzavik V, Reynolds HR, Abramsky SJ, et al. Coronary intervention for persistent occlusion after myocardial infarction. N Engl J Med. 2006. 355(23):2395-407. [Medline].
Wald DS, Morris JK, Wald NJ, Chase AJ, Edwards RJ, Hughes LO, et al. Randomized trial of preventive angioplasty in myocardial infarction. N Engl J Med. 2013. 369(12):1115-23. [Medline].
Piccolo R, Gu YL, Iversen AZ, Dominguez-Rodriguez A, de Smet BJ, Mahmoud KD, et al. Clinical impact of intracoronary abciximab in patients undergoing primary percutaneous coronary intervention: an individual patient data pooled analysis of randomised studies. Heart. 2012. [Medline].
Stone GW, Maehara A, Witzenbichler B, Godlewski J, Parise H, Dambrink JH, et al. Intracoronary abciximab and aspiration thrombectomy in patients with large anterior myocardial infarction: the INFUSE-AMI randomized trial. JAMA. 2012. 307(17):1817-26. [Medline].
Harrison RW, Aggarwal A, Ou FS, Klein LW, Rumsfeld JS, Roe MT, et al. Incidence and outcomes of no-reflow phenomenon during percutaneous coronary intervention among patients with acute myocardial infarction. Am J Cardiol. 2013. 111(2):178-84. [Medline].
Reifart N, Vandormael M, Krajcar M, Gohring S, Preusler W, Schwarz F, et al. Randomized comparison of angioplasty of complex coronary lesions at a single center. Excimer Laser, Rotational Atherectomy, and Balloon Angioplasty Comparison (ERBAC) Study. Circulation. 1997. 96(1):91-8. [Medline].
Baim DS, Wahr D, George B, Leon MB, Greenberg J, Cutlip DE, et al. Randomized trial of a distal embolic protection device during percutaneous intervention of saphenous vein aorto-coronary bypass grafts. Circulation. 2002. 105(11):1285-90. [Medline].
Zimarino M, Corcos T, Favereau X, Commeau P, Tamburino C, Spaulding C, et al. Rotational coronary atherectomy with adjunctive balloon angioplasty for the treatment of ostial lesions. Cathet Cardiovasc Diagn. 1994. 33(1):22-7. [Medline].
Stone GW, Kedhi E, Kereiakes DJ, Parise H, Fahy M, Serruys PW, et al. Differential clinical responses to everolimus-eluting and Paclitaxel-eluting coronary stents in patients with and without diabetes mellitus. Circulation. 2011. 124(8):893-900. [Medline].
Baber U, Mehran R, Sharma SK, Brar S, Yu J, Suh JW, et al. Impact of the everolimus-eluting stent on stent thrombosis: a meta-analysis of 13 randomized trials. J Am Coll Cardiol. 2011. 58(15):1569-77. [Medline].
Bangalore S, Amoroso N, Fusaro M, Kumar S, Feit F. Outcomes with various drug-eluting or bare metal stents in patients with ST-segment-elevation myocardial infarction: a mixed treatment comparison analysis of trial level data from 34 068 patient-years of follow-up from randomized trials. Circ Cardiovasc Interv. 2013. 6(4):378-90. [Medline].
Piscione F, Piccolo R, Cassese S, Galasso G, D’Andrea C, De Rosa R, et al. Is direct stenting superior to stenting with predilation in patients treated with percutaneous coronary intervention? Results from a meta-analysis of 24 randomised controlled trials. Heart. 2010. 96(8):588-94. [Medline].
Vlaar PJ, Svilaas T, van der Horst IC, Diercks GF, Fokkema ML, de Smet BJ, et al. Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study. Lancet. 2008. 371(9628):1915-20. [Medline].
De Vita M, Burzotta F, Porto I, Dudek D, Lefevre T, Trani C, et al. Thrombus aspiration in ST elevation myocardial infarction: comparative efficacy in patients treated early and late after onset of symptoms. Heart. 2010. 96(16):1287-90. [Medline].
Frobert O, Lagerqvist B, Olivecrona GK, Omerovic E, Gudnason T, Maeng M, et al. Thrombus aspiration during ST-segment elevation myocardial infarction. N Engl J Med. 2013. 369(17):1587-97. [Medline].
Lagerqvist B, Frobert O, Olivecrona GK, Gudnason T, Maeng M, Alstrom P, et al. Outcomes 1 year after thrombus aspiration for myocardial infarction. N Engl J Med. 2014. 371(12):1111-20. [Medline].
Kaltoft A, Kelbaek H, Klovgaard L, Terkelsen CJ, Clemmensen P, Helqvist S, et al. Increased rate of stent thrombosis and target lesion revascularization after filter protection in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: 15-month follow-up of the DEDICATION (Drug Elution and Distal Protection in ST Elevation Myocardial Infarction) trial. J Am Coll Cardiol. 2010. 55(9):867-71. [Medline].
Biancari F, D’Andrea V, Di Marco C, Savino G, Tiozzo V, Catania A. Meta-analysis of randomized trials on the efficacy of vascular closure devices after diagnostic angiography and angioplasty. Am Heart J. 2010. 159(4):518-31. [Medline].
Nikolsky E, Mehran R, Halkin A, Aymong ED, Mintz GS, Lasic Z, et al. Vascular complications associated with arteriotomy closure devices in patients undergoing percutaneous coronary procedures: a meta-analysis. J Am Coll Cardiol. 2004. 44(6):1200-9. [Medline].
Vaitkus PT. A meta-analysis of percutaneous vascular closure devices after diagnostic catheterization and percutaneous coronary intervention. J Invasive Cardiol. 2004. 16(5):243-6. [Medline].
Koreny M, Riedmuller E, Nikfardjam M, Siostrzonek P, Mullner M. Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: systematic review and meta-analysis. JAMA. 2004. 291(3):350-7. [Medline].
Brar SS, Aharonian V, Mansukhani P, Moore N, Shen AY, Jorgensen M, et al. Haemodynamic-guided fluid administration for the prevention of contrast-induced acute kidney injury: the POSEIDON randomised controlled trial. Lancet. 2014. 383(9931):1814-23. [Medline].
Investigators ACT. Acetylcysteine for prevention of renal outcomes in patients undergoing coronary and peripheral vascular angiography: main results from the randomized Acetylcysteine for Contrast-induced nephropathy Trial (ACT). Circulation. 2011. 124(11):1250-9. [Medline].
Romagnoli E, Biondi-Zoccai G, Sciahbasi A, Politi L, Rigattieri S, Pendenza G, et al. Radial versus femoral randomized investigation in ST-segment elevation acute coronary syndrome: the RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) study. J Am Coll Cardiol. 2012. 60(24):2481-9. [Medline].
Jolly SS, Yusuf S, Cairns J, Niemela K, Xavier D, Widimsky P, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011. 377(9775):1409-20. [Medline].
Rao SV, Tremmel JA, Gilchrist IC, Shah PB, Gulati R, Shroff AR, et al. Best practices for transradial angiography and intervention: a consensus statement from the society for cardiovascular angiography and intervention’s transradial working group. Cathet Cardiovasc Interv. 2014. 83(2):228-36. [Medline].
Cavusoglu E, Kini AS, Marmur JD, Sharma SK. Current status of rotational atherectomy. Cathet Cardiovasc Interv. 2004. 62(4):485-98. [Medline].
Pijls NH, Fearon WF, Tonino PA, Siebert U, Ikeno F, Bornschein B, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention in patients with multivessel coronary artery disease: 2-year follow-up of the FAME (Fractional Flow Reserve Versus Angiography for Multivessel Evaluation) study. J Am Coll Cardiol. 2010. 56(3):177-84. [Medline].
De Bruyne B, Fearon WF, Pijls NH, Barbato E, Tonino P, Piroth Z, et al. Fractional flow reserve-guided PCI for stable coronary artery disease. N Engl J Med. 2014. 371(13):1208-17. [Medline].
Serruys PW, Herrman JP, Simon R, Rutsch W, Bode C, Laarman GJ, et al. A comparison of hirudin with heparin in the prevention of restenosis after coronary angioplasty. Helvetica Investigators. N Engl J Med. 1995. 333(12):757-63. [Medline].
Burchenal JE, Marks DS, Tift Mann J, Schweiger MJ, Rothman MT, Ganz P, et al. Effect of direct thrombin inhibition with Bivalirudin (Hirulog) on restenosis after coronary angioplasty. Am J Cardiol. 1998. 82(4):511-5. [Medline].
Bittl JA, Strony J, Brinker JA, Ahmed WH, Meckel CR, Chaitman BR, et al. Treatment with bivalirudin (Hirulog) as compared with heparin during coronary angioplasty for unstable or postinfarction angina. Hirulog Angioplasty Study Investigators. N Engl J Med. 1995. 333(12):764-9. [Medline].
Mehran R, Lansky AJ, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, et al. Bivalirudin in patients undergoing primary angioplasty for acute myocardial infarction (HORIZONS-AMI): 1-year results of a randomised controlled trial. Lancet. 2009. 374(9696):1149-59. [Medline].
Lopes RD, Alexander KP, Manoukian SV, Bertrand ME, Feit F, White HD, et al. Advanced age, antithrombotic strategy, and bleeding in non-ST-segment elevation acute coronary syndromes: results from the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial. J Am Coll Cardiol. 2009. 53(12):1021-30. [Medline].
Tavano D, Visconti G, D’Andrea D, Focaccio A, Golia B, Librera M, et al. Comparison of bivalirudin monotherapy versus unfractionated heparin plus tirofiban in patients with diabetes mellitus undergoing elective percutaneous coronary intervention. Am J Cardiol. 2009. 104(9):1222-8. [Medline].
Steg PG, van ‘t Hof A, Hamm CW, Clemmensen P, Lapostolle F, Coste P, et al. Bivalirudin started during emergency transport for primary PCI. N Engl J Med. 2013. 369(23):2207-17. [Medline].
Shahzad A, Kemp I, Mars C, Wilson K, Roome C, Cooper R, et al. Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial. Lancet. 2014 Nov 22. 384(9957):1849-58. [Medline].
Dangas G, Mehran R, Guagliumi G, Caixeta A, Witzenbichler B, Aoki J, et al. Role of clopidogrel loading dose in patients with ST-segment elevation myocardial infarction undergoing primary angioplasty: results from the HORIZONS-AMI (harmonizing outcomes with revascularization and stents in acute myocardial infarction) trial. J Am Coll Cardiol. 2009. 54(15):1438-46. [Medline].
Price MJ, Berger PB, Teirstein PS, Tanguay JF, Angiolillo DJ, Spriggs D, et al. Standard- vs high-dose clopidogrel based on platelet function testing after percutaneous coronary intervention: the GRAVITAS randomized trial. JAMA. 2011. 305(11):1097-105. [Medline].
Mega JL, Simon T, Collet JP, Anderson JL, Antman EM, Bliden K, et al. Reduced-function CYP2C19 genotype and risk of adverse clinical outcomes among patients treated with clopidogrel predominantly for PCI: a meta-analysis. JAMA. 2010. 304(16):1821-30. [Medline].
Siller-Matula JM, Trenk D, Schror K, Gawaz M, Kristensen SD, Storey RF, et al. Response variability to P2Y12 receptor inhibitors: expectations and reality. JACC Cardiovasc Intervent. 2013. 6(11):1111-28. [Medline].
Angiolillo DJ, Ferreiro JL, Price MJ, Kirtane AJ, Stone GW. Platelet function and genetic testing. J Am Coll Cardiol. 2013. 62(17 Suppl):S21-31. [Medline].
Bhatt DL, Cryer BL, Contant CF, et al. COGENT Investigators. Clopidogrel with or without omeprazole in coronary artery disease. N Engl J Med. 2010 Nov 11. 363(20):1909-17. [Medline].
Morrow DA, Wiviott SD, White HD, Nicolau JC, Bramucci E, Murphy SA, et al. Effect of the novel thienopyridine prasugrel compared with clopidogrel on spontaneous and procedural myocardial infarction in the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction 38: an application of the classification system from the universal definition of myocardial infarction. Circulation. 2009. 119(21):2758-64. [Medline].
Wallentin L, Becker RC, Budaj A, et al. PLATO Investigators, Freij A, Thorsén M. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009 Sep 10. 361(11):1045-57. [Medline].
Lincoff AM, Tcheng JE, Califf RM, Kereiakes DJ, Kelly TA, Timmis GC, et al. Sustained suppression of ischemic complications of coronary intervention by platelet GP IIb/IIIa blockade with abciximab: one-year outcome in the EPILOG trial. Evaluation in PTCA to Improve Long-term Outcome with abciximab GP IIb/IIIa blockade. Circulation. 1999. 99(15):1951-8. [Medline].
Zeymer U, Margenet A, Haude M, Bode C, Lablanche JM, Heuer H, et al. Randomized comparison of eptifibatide versus abciximab in primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction: results of the EVA-AMI Trial. J Am Coll Cardiol. 2010. 56(6):463-9. [Medline].
Winchester DE, Wen X, Brearley WD, Park KE, Anderson RD, Bavry AA. Efficacy and safety of glycoprotein IIb/IIIa inhibitors during elective coronary revascularization: a meta-analysis of randomized trials performed in the era of stents and thienopyridines. J Am Coll Cardiol. 2011. 57(10):1190-9. [Medline].
Daugherty SL, Thompson LE, Kim S, Rao SV, Subherwal S, Tsai TT, et al. Patterns of use and comparative effectiveness of bleeding avoidance strategies in men and women following percutaneous coronary interventions: an observational study from the National Cardiovascular Data Registry. J Am Coll Cardiol. 2013. 61(20):2070-8. [Medline].
Feldman DN, Swaminathan RV, Kaltenbach LA, Baklanov DV, Kim LK, Wong SC, et al. Adoption of radial access and comparison of outcomes to femoral access in percutaneous coronary intervention: an updated report from the national cardiovascular data registry (2007-2012). Circulation. 2013. 127(23):2295-306. [Medline].
Stone GW, Ellis SG, Colombo A, Dawkins KD, Grube E, Cutlip DE, et al. Offsetting impact of thrombosis and restenosis on the occurrence of death and myocardial infarction after paclitaxel-eluting and bare metal stent implantation. Circulation. 2007. 115(22):2842-7. [Medline].
Mayer K, Bernlochner I, Braun S, Schulz S, Orban M, Morath T, et al. Aspirin treatment and outcomes after percutaneous coronary intervention: results of the ISAR-ASPI registry. J Am Coll Cardiol. 2014. 64(9):863-71. [Medline].
|Endpoint||Pocock et al*||Pocock et al†||BARI Study‡|
|Death or MI||4.5||7.2||8.5||8.1||11.7||10.9|
|Repeat CABG or PTCA||3.6||30.5§||3.2||34.5§||8.0||54.0§|
|More than mild angina||6.5||14.6§||12.1||17.8§||...||...|
|*Meta-analysis of results of 3 trials at 1 year. Patients with single-vessel disease were studied.
†Meta-analysis of results of 3 trials at 1 year. Patients with multivessel disease were studied.
‡Reported results are for 5-year follow-up. Patients with multivessel disease were studied.
§ P < .05.
BARI = Bypass Angioplasty Revascularization Investigation; CABG = coronary artery bypass grafting; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty.