Senior Consultant & Unit Head, Interventional Cardiology, BLK-Max Super Speciality Hospital, New Delhi
Part 5 of 8 in Diagnosis and Management of Acute Coronary Artery Disease
How PCI (Angioplasty) Is Performed, and When Bypass Is Better
June 2, 2024
PCI, commonly known as angioplasty, is the standard way of opening a blocked coronary artery, though not every blockage is suited to it.
How PCI is performed
Access is gained through either the radial artery in the wrist or the femoral artery in the groin. An angiogram is performed first through a catheter placed in that artery to locate the blockages and plan treatment. A wire is then passed across the blockage, a balloon is used to open it, and a stent is placed to keep the artery open. In an acute heart attack, this directly clears the thrombus, places a stent, and restores blood flow.
When bypass surgery is preferred instead
When there are multiple complex blockages that would require an excessive number of stents, coronary artery bypass surgery is recommended instead of PCI. This decision is made through a heart-team approach, discussing each patient's angiography with the cardiac surgery (CTVS) team to decide between stenting and bypass. Complex procedures such as left main interventions, bifurcation angioplasty, rotablation and intracoronary lithotripsy for heavily calcified arteries, and mechanical support devices like Impella and IABP for critically unstable patients, are all performed routinely.
This article is based on a Jivo Masterclass session conducted by Dr. Vikas Thakran, Senior Consultant & Unit Head, Interventional Cardiology, BLK-Max Super Speciality Hospital, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Vikas Thakran taught doctors across Africa on June 2, 2024.
FROM THE LIVE Q&A
Moderator
What are the main causes of acute coronary syndrome?
Dr. Vikas Thakran
Smoking in young patients, diabetes, hypertension, a family history of cardiac disease, a sedentary lifestyle, and lack of sleep are the major risk factors. Pollution and extremes of temperature can also precipitate an event.
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Frequently Asked Questions
What is the role of cardiac defibrillation?▼
During an acute coronary event, external defibrillation is used for life-threatening ventricular tachycardia or ventricular fibrillation, whether at presentation, during the procedure, or post-operatively. On longer-term follow-up, patients with poor heart function (a low ejection fraction) may need an ICD, a device similar to a pacemaker, implanted to protect against these arrhythmias.
What are the expected complications of an angioplasty procedure?▼
Angioplasty is roughly 95 to 98% safe. The complications that can occur are access-site bleeding from the hand or groin, and rarer complications related to the coronary arteries themselves, such as stent thrombosis (a blocked stent) or, in difficult vessels, a perforation.
What motivates this line of work?▼
A heart attack patient left untreated has a 30 to 50% chance of dying; treated promptly with a procedure or thrombolysis, that risk falls to around 5%. Saving the largest number of lives in the smallest amount of time, across the globe, is the reason and the motivation.
For a patient with anterior wall MI who has also fainted and is in a critical condition, how do you manage evacuation to an Indian hospital?▼
Jivo's international team manages the entire process end to end, from the visa process to ambulance transfer at the airport, and makes sure family members travelling with the patient are comfortable too. They first take the patient's details and advise on the right course of action, so the point of contact should be the international team, who will coordinate directly with BLK-Max.
How is a PCI (angioplasty) actually performed?▼
Access is gained through either the radial artery in the wrist or the femoral artery in the groin. An angiography is first done through a catheter placed in that artery to locate the blockages, and a treatment plan is formed. A wire is then passed across the blockage, a balloon is used to open it, and a stent is placed. If there are multiple complex blockages that would need too many stents, coronary artery bypass surgery is recommended instead, decided by a heart-team approach. In an acute heart attack, PCI directly clears the thrombus, places a stent, and restores flow.
How is PCI (angioplasty) performed?▼
Through a catheter placed via the radial or femoral artery, an angiogram locates the blockage, then a wire, balloon and stent are used to open and keep the artery open.
When is bypass surgery recommended instead of PCI?▼
When there are multiple complex blockages that would require an excessive number of stents, decided through a heart-team approach with the cardiac surgery team.
In This Series: Diagnosis and Management of Acute Coronary Artery Disease
- 1.Acute Coronary Syndrome
- 2.How a Heart Attack Develops: From Plaque to Complete Blockage
- 3.STEMI, NSTEMI and Unstable Angina: Reading the ECG
- 4.Managing a Heart Attack: STEMI vs NSTEMI Protocols
- 5.How PCI (Angioplasty) Is Performed, and When Bypass Is Better
- 6.Angioplasty: Complication Rates and Why Fast Treatment Matters
- 7.Heart Attack Risk Factors, Nitrate Therapy and Nutrition
- 8.Hospital Facilities and Evacuating Critical Patients Internationally