Percutaneous coronary intervention. II: The procedureBMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7399.1137 (Published 22 May 2003) Cite this as: BMJ 2003;326:1137
- Ever D Grech, consultant cardiologist, assistant professor
- Health Sciences Centre and St Boniface Hospital, Winnipeg, Manitoba, Canada, University of Manitoba, Winnipeg.
A wide range of patients may be considered for percutaneous coronary intervention. It is essential that the benefits and risks of the procedure, as well as coronary artery bypass graft surgery and medical treatment, are discussed with patients (and their families) in detail. They must understand that, although the percutaneous procedure is more attractive than bypass surgery, it has important limitations, including the likelihood of restenosis and potential for incomplete revascularisation compared with surgery. The potential benefits of antianginal drug treatment and the need for risk factor reduction should also be carefully explained.
Clinical risk assessment
Relief of anginal symptoms is the principal clinical indication for percutaneous intervention, but we do not know whether the procedure has the same prognostic benefit as bypass surgery. Angiographic features determined during initial assessment require careful evaluation to determine the likely success of the procedure and the risk of serious complications.
Until recently, the American College of Cardiology and American Heart Association classified anginal lesions into types (and subtypes) A, B, or C based on the severity of lesion characteristics. Because of the ability of stents to overcome many of the complications of percutaneous intervention, this classification has now been superseded by one reflecting low, moderate, and high risk.
Successful percutaneous intervention depends on adequate visualisation of the target stenosis and its adjacent arterial branches. Vessels beyond the stenosis may also be important because of the potential for collateral flow and myocardial support if the target vessel were to occlude abruptly. Factors that adversely affect outcome include increasing age, comorbid disease, unstable angina, pre-existing heart or renal failure, previous myocardial infarction, diabetes, a large area of myocardium at risk, degree of collaterisation, and multivessel disease.
Preparation for intervention
Patients must be fully informed of the purpose of the procedure as well as its risks and limitations before they are asked …