Percutaneous Transluminal Coronary Angioplasty (PTCA)


Article Author:
Talia Malik


Article Editor:
Vijai Tivakaran


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
12/15/2018 3:53:04 PM

Introduction

Percutaneous transluminal coronary angioplasty (PTCA) also called percutaneous coronary intervention (PCI) is a minimally invasive procedure to open blocked or stenosed coronary arteries allowing unobstructed blood flow to the myocardium. The blockages occur because of lipid-rich plaque within the arteries, diminishing blood flow to the myocardium. The accumulation of lipid-rich plaque in the arteries is known as atherosclerosis. When atherosclerosis affects the coronary arteries, the disorder is known as coronary artery disease.  Patients with CAD usually present with exertional chest pain, or with dyspnea with exertion. In acute myocardial infarction, there is plaque rupture with platelet aggregation, and acute thrombus formation, which results in a sudden occlusion of the coronary artery. These patients present with acute chest heaviness, diaphoresis, and nausea. Urgent PTCA is often required to limit myocardial damage.

Andreas Gruentzig first developed PCTA in 1977, and the procedure was performed in Zurich, Switzerland that same year.[1] By the mid-1980s many leading institutions adopted this procedure throughout the world as a treatment for coronary artery disease. PTCA is a hallmark procedure and basis of many other intracoronary interventions. It is one of the most common procedures performed in the United States making up 3.6% of all operating room procedures performed in 2011.

Anatomy

The 2, main coronary arteries supplying the heart are the right and left coronary arteries. The left coronary artery (LCA) divides into left anterior descending (LAD) and left circumflex iliac (LCX) branches. LCA supplies blood to the left ventricle of the heart. The right coronary artery (RCA) divides into the right posterior descending (PDA) and a (PL) posterolateral branch. RCA supplies blood to the ventricles, right atrium and sinoatrial node. Coronary arteries are end-arteries supplying the myocardium and blockage can lead to serious adverse effects. Coronary artery disease occurs due to the buildup of plaque within the coronary arteries with subsequent narrowing and blockage reducing blood flow to the myocardium.

Indications

Indications of PTCA depend on various factors. Patients with stable angina symptoms unresponsive to maximal medical therapy will benefit from PCI. It helps provide relief of persistent angina symptoms despite maximal medical therapy.[2] Emergency PTCA is indicated for acute ST-elevation myocardial infarction (STEMI) suggesting 100% occlusion of the coronary artery. With acute STEMI, patients are taken directly to cath lab immediately upon presentation to help prevent further myocardial muscle damage. In non-ST-elevation myocardial infarction (NSTEMI), or unstable angina, (known as acute coronary syndromes), patients are taken to cardiac cath lab within 24 to 48 hours.

Contraindications

PTCA has limited contraindications. Patients with left main CAD are poor candidates for the procedure due to the risk of acute obstruction or spasm of the left main coronary artery during the procedure. It is also not recommended for patients with hemodynamically insignificant (less than 70%) stenosis of the coronary arteries.

Equipment

Initially, PCI was performed using balloon catheters alone. However, due to subclinical outcomes and vessel re-stenosis, other devices were introduced including atherectomy devices and coronary stents. Atherectomy devices used alone resulted in poor outcomes. Coronary stents are the most widely used intracoronary devices in PTCA due to improved clinical outcomes. Various types of stents are available including traditional bare-metal stents (BMS) and drug-eluting stents (DES). DES has a polymer coating that prevents inflammation and endothelial cell proliferation. Most recent DES used in the United States use sirolimus, everolimus, and zotarolimus. The newer generation DES have reduced the incidence of late stent thrombosis.[3] The use of antiplatelet therapy is important during the first 12 months after PTCA, allowing appropriate duration for endothelial cell formation over the metallic stent to prevent stent thrombosis.

Personnel

A team made up of an interventional cardiologist, nurse, and radiology technologist performs PTCA. All team members must have specialized and extensive training in the procedure.

Preparation

An interprofessional team evaluates the patients and performs pre-procedural testing to determine candidacy for the procedure. The inquiry related to the past history of allergy to seafood or contrast agents is vital. Important pre-procedure laboratory tests include PT and PTT, serum electrolytes, BUN, and creatinine. The patient is required to be well hydrated. Medication review is essential including cessation of anticoagulants if possible. Also, common medications including NSAIDs, or ACEIs can be held to prevent worsening renal insufficiency. The diabetes medication metformin is held prior to cardiac catheterization to avoid worsening renal insufficiency and lactic acidosis. Fluids and food are restricted 6 to 8 hours before the procedure. When cases are performed via radial artery access, patients are often given intra-arterial calcium channel blocker, nitroglycerin, and heparin to prevent vasospasm. The health care provider should thoroughly explain the procedure and its associated risks and complications to the patient to obtain a signed informed consent.

Technique

The procedure is performed under local anesthesia. Conscious sedation is routinely given to avoid stress and calm the patient. Most commonly used approach is the percutaneous femoral (Judkins) approach. Once the patient is anesthetized with a superficial injection of lidocaine to the skin, and subcutaneous tissues over the right femoral artery, a needle is inserted into the femoral artery (percutaneous access). Successful insertion of the needle is followed by insertion of a guide wire through the needle into the lumen of the blood vessel. The needle is then removed with the guide wire remaining in the vessel lumen. A sheath with introducer is placed over the guide wire and into the femoral artery. Next, the guide wire and introducer is removed, leaving the sheath in the vessel lumen. This provides easy access to the femoral artery lumen. Next, a long narrow tube, known as the "diagnostic catheter," is advanced through the sheath with a long guidewire in the catheter lumen. The diagnostic catheter follows the guide wire and is passed retrograde through the femoral artery, iliac artery, descending aorta, over the aortic arch to the proximal ascending aorta. The guide wire is removed leaving the tip of the diagnostic catheter in the ascending aorta. The diagnostic catheter is attached to a manifold with a syringe. The manifold allows the ability to inject contrast, check inter-arterial pressure, and administer medications.

The diagnostic catheter is then manipulated into the ostium of the left main coronary artery, or right coronary artery. Contrast dye is injected, and cineangiography images are obtained in multiple views of both arteries. If severe stenosis exists in one of the arteries, PTCA can be performed. The diagnostic catheter is removed and exchanged for a similar guide catheter. Guide catheters have a larger luminal diameter for ease of passage of wires and balloons during angioplasty. After the guide catheter is placed in the ostium of the respective artery, a PTCA guide wire is advanced through the catheter and across the stenosis. Once the PTCA guide wire is passed across the stenosis, it is left in place until the end of the procedure. A balloon wire can be placed over the PTCA guide wire and advanced until the balloon is directly over the stenosis. The cardiologist controls the direction and movement of the PTCA guide wire, and balloon wire by twisting the part of guide wires that sit outside the patient. The balloon is then inflated and deflated repeatedly until the artery is patent. In most instances, a stent is required. The balloon wire is removed and exchanged for a stent. A stent is a latticed metal scaffold that is delivered crimped over a balloon of a balloon wire. The stent is then placed in the position of the stenosis, and the balloon expanded. Once the stent is expanded, it cannot be removed from the artery. The balloon is deflated, and the stent remains in place. The stent can maintain long-term patency. Repeated injections of contrast media are utilized to check for patency of the artery.

Upon successful insertion of the stent and expansion of the vessel, the balloon wire is removed. Lastly, the PTCA guide wire is removed. During the procedure, anticoagulation is administered to prevent the formation of clots. The entire procedure can take from 30 minutes to 3 hours depending upon the technical difficulties of the case.

Complications

PTCA is widely practiced and has risks, but major procedural complications are rare. The mortality rate during angioplasty is 1.2%.[4] People older than the age of 65, with kidney disease or diabetes, women and those with massive heart disease are at a higher risk for complications. Possible complications include hematoma at the femoral artery insertion site, pseudoaneurysm of the femoral artery, infection of skin over femoral artery, embolism, stroke, kidney injury from contrast dye, hypersensitivity to dye, vessel rupture, coronary artery dissection, bleeding, vasospasm, thrombus formation, and acute MI. There is a long-term risk of re-stenosis of the stented vessel.

Clinical Significance

PTCA is performed under local anesthesia and serves as an alternative to coronary artery bypass surgery (CABG). In comparison to CABG, PTCA is associated with lower morbidity and mortality, shorter convalescence and lower cost. It can significantly improve blood flow through the coronary arteries in about 90% of patients with relief of anginal symptoms and improvement in exercise capacity. It effectively eliminates arterial narrowing in most cases. Different modeling studies presented different conclusions regarding the cost-effectiveness of PTCA and CABG in patients of myocardial ischemia that do not respond to medical therapy.[5][6][7]

Enhancing Healthcare Team Outcomes

PTCA is not an easy procedure, and despite the advances in technology, it has risks and complications. All patients need to be educated about the procedure and its potential complications. Maintaining a healthy diet, exercising, and reducing stress are important post-procedural measures to reduce the risk of recurrences and complications. The heart team illustrates an excellent example of patient-centered care. Experts from different fields of medicine come together to provide the best solution for each patient.[8]


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    Contributed by Nelson Telles
Attributed To: Contributed by Nelson Telles

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Percutaneous Transluminal Coronary Angioplasty (PTCA) - Questions

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Two days after undergoing angioplasty, a 63-year-old male with coronary artery disease presents with a web-like discoloration that is blue-white in appearance. It is seen on both legs and, primarily, on the soles of his feet. What is the most likely cause of this presentation?



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A 65-year-old man presents with acute onset of severe chest pain radiating toward the left arm, diaphoresis and nausea. On evaluation, an ST-segment elevation myocardial infarction is diagnosed, when is the best time for percutaneous coronary intervention in this patient?



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A percutaneous angioplasty after a myocardial infarction is usually done via which of the following vessels?



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After the use of contrast during a percutaneous transluminal coronary angioplasty, which of the following is most likely to occur?



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Many studies have been conducted on the benefits and long-term outcome of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG). Both treatments have proven efficacy in the treatment of coronary artery disease. PTCA compared to CABG is less invasive and most cost-effective. It is more cost-effective than CABG for how long?



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Percutaneous transluminal coronary angioplasty (PTCA) is a safe procedure; however, it still has certain risks and complications. Among the complications. Coronary artery spasm is a dangerous complication which can lead to adverse outcomes. Which of the following is not a part of the management of coronary spasm during PTCA?



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Select the correct statement about percutaneous coronary interventions (PCI).



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The GUSTO II trial compares tPA with:



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Which of the following is not an independent predictor of late mortality in patients with acute myocardial infarction and prior coronary artery bypass graft receiving percutaneous transluminal coronary angioplasty (PTCA) ?



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A 70-year-old obese man presents to the emergency department complaining of stabbing chest pain and diaphoresis. He has had chest pain with exertion in the past. Upon evaluation, myocardial infarction is diagnosed, and a decision is made to perform percutaneous transluminal coronary angioplasty (PTCA). Which drug is discontinued before the procedure?



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A 63-year-old female who is extremely obese presented to a cardiology office 3 days after receiving elective cardiac catheterization with percutaneous transluminal coronary angioplasty (PTCA) and stenting of the right coronary artery. She developed a right groin hematoma after the procedure, which was treated conservatively by cath lab staff by holding pressure and mechanical clamping. She was discharged postoperative day 1 with outpatient cardiology follow up. Now, on postoperative day 3, she denies angina or chest pain with exertion. She is compliant with antiplatelet therapy. The physical exam reveals a tender, right groin 3 cm by 4 cm pulsatile mass. There is an audible systolic bruit noted over the access site. Which of the following would be the next step in management?



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A 57-year-old male who is extremely obese had cardiac catheterization via the right femoral artery approach. Due to his extreme obesity and large pannus, a right femoral artery puncture was attempted multiple times before access was achieved and the sheath was placed. The patient tolerated the procedure well, and only moderate coronary artery disease was noted. In the postprocedural period, his vital signs reveal mild tachycardia and steadily declining blood pressure. The patient is complaining of right-sided low back pain. There is no obvious hematoma. What is the best next step in management?



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A 57-year-old male with a past history of known coronary artery disease, diabetes mellitus, and hypertension presents for preoperative risk assessment before hip replacement surgery. He jogs 3 miles in 30 minutes 5 days per week. He denies any cardiac symptoms with this activity. His EKG shows sinus rhythm and no acute ST changes. He had a percutaneous coronary intervention (PCI) with a drug-eluting stent to the left anterior descending artery 13 months ago. Which of the following would be appropriate recommendations before proceeding with elective hip surgery?



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A 64-year-old male with a past history of diabetes mellitus, hypertension, and hyperlipidemia presented with an NSTEMI. He received cardiac catheterization via the radial approach. He received percutaneous coronary intervention (PCI) to the right coronary artery (RCA) and tolerated the procedure well. The benefits of the radial approach over the femoral artery approach include which of the following?



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A 65-year-old male with a history of hypertension, hyperlipidemia, and alcohol use disorder presents with an acute inferior wall ST-elevation myocardial infarction. Based on his history, you have concerns about medication noncompliance. Coronary angiography reveals 100% stenosis in the proximal right coronary artery (RCA) and no stenosis in the left anterior descending artery (LAD) or left circumflex artery (LCx). The RCA is opened by passing the guide wire, and there is resolution of both the chest pain symptoms and ST segment elevations on the monitor. The patient requires a 4 mm by 12 mm stent. Which of the following would be the best choice for this patient who potentially will be noncompliant with taking medication?



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Percutaneous Transluminal Coronary Angioplasty (PTCA) - References

References

Meier B,Bachmann D,Lüscher T, 25 years of coronary angioplasty: almost a fairy tale. Lancet (London, England). 2003 Feb 8     [PubMed]
Pursnani S,Korley F,Gopaul R,Kanade P,Chandra N,Shaw RE,Bangalore S, Percutaneous coronary intervention versus optimal medical therapy in stable coronary artery disease: a systematic review and meta-analysis of randomized clinical trials. Circulation. Cardiovascular interventions. 2012 Aug 1     [PubMed]
Palmerini T,Benedetto U,Biondi-Zoccai G,Della Riva D,Bacchi-Reggiani L,Smits PC,Vlachojannis GJ,Jensen LO,Christiansen EH,Berencsi K,Valgimigli M,Orlandi C,Petrou M,Rapezzi C,Stone GW, Long-Term Safety of Drug-Eluting and Bare-Metal Stents: Evidence From a Comprehensive Network Meta-Analysis. Journal of the American College of Cardiology. 2015 Jun 16     [PubMed]
Welsh RC,Granger CB,Westerhout CM,Blankenship JC,Holmes DR Jr,O'Neill WW,Hamm CW,Van de Werf F,Armstrong PW, Prior coronary artery bypass graft patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. JACC. Cardiovascular interventions. 2010 Mar     [PubMed]
Stroupe KT,Morrison DA,Hlatky MA,Barnett PG,Cao L,Lyttle C,Hynes DM,Henderson WG, Cost-effectiveness of coronary artery bypass grafts versus percutaneous coronary intervention for revascularization of high-risk patients. Circulation. 2006 Sep 19     [PubMed]
Osnabrugge RL,Magnuson EA,Serruys PW,Campos CM,Wang K,van Klaveren D,Farooq V,Abdallah MS,Li H,Vilain KA,Steyerberg EW,Morice MC,Dawkins KD,Mohr FW,Kappetein AP,Cohen DJ, Cost-effectiveness of percutaneous coronary intervention versus bypass surgery from a Dutch perspective. Heart (British Cardiac Society). 2015 Dec     [PubMed]
Zhang Z,Kolm P,Grau-Sepulveda MV,Ponirakis A,O'Brien SM,Klein LW,Shaw RE,McKay C,Shahian DM,Grover FL,Mayer JE,Garratt KN,Hlatky M,Edwards FH,Weintraub WS, Cost-effectiveness of revascularization strategies: the ASCERT study. Journal of the American College of Cardiology. 2015 Jan 6     [PubMed]
Movahed MR,Hashemzadeh M,Jamal MM,Ramaraj R, Decreasing in-hospital mortality of patients undergoing percutaneous coronary intervention with persistent higher mortality rates in women and minorities in the United States. The Journal of invasive cardiology. 2010 Feb     [PubMed]

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