Topic #47: Indications and Complications of Angioplasty
Dean Karvellas
Sources: Uptodate and Rob Welsh’s talk
Indications for immediate (invasive) angiography
 Acute STEMI
 UA or NSTEMI are deemed to be at such high risk of death or a
complicated MI that early coronary arteriography is recommended with
an intention to proceed to immediate revascularization if possible
o Hemodynamic instability with or without cardiogenic shock
o Severe LV dysfunction (<40%) or CHF
o Recurrent or persistent rest angina despite intensive medical
therapy.
o Mechanical complications (Acute MR or VSD)
o Sustained ventricular tachycardia.
o Elevated cardiac biomarkers
o New/presumably new ST-segment depression
o Signs or symptoms of HF or new/worsening mitral regurgitation
o High-risk findings from noninvasive testing
o PCI within 6 months
o Prior CABG
o High TIMI risk score
TIMI risk score — The TIMI risk score was developed in an attempt to risk
stratify patients with UA or NSTEMI. It is a validated risk prediction model, based
upon data from the TIMI 11B and ESSENCE trials
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Age ≥65 years
Presence of at least three risk factors for CHD
Prior coronary stenosis of ≥50 percent
Presence of ST segment deviation on admission ECG
At least two anginal episodes in prior 24 hours
Elevated serum cardiac biomarkers
Use of aspirin in prior seven days
A higher TIMI risk score correlated significantly with increased numbers of events
(all-cause mortality, new or recurrent MI, or severe recurrent ischemia requiring
revascularization) at 14 days (show calculator):
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Score of 0/1 - 4.7 percent
Score of 2 - 8.3 percent
Score of 3 - 13.2 percent
Score of 4 - 19.9 percent
Score of 5 - 26.2 percent
Score of 6/7 - 40.9 percent
Treatment with Coronary Angioplasty
Initiate anticoagulant therapy as soon as possible after presentation (I, A)
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Enoxaparin or UFH (I, A)
Bivalirudin or fondaparinux (I, B)
Prior to angiography, initiate one (I, A) or both (IIa, B)
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Clopidogrel
IV GP IIb/IIIa inhibitor
Use both if:
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Delay to angiography
High risk features or early recurrent ischemic symptoms
Complications of Angioplasty
Predictors of mortality and major complications
 Influence of hospital (> 400/year) and operator volume(>75/year)
 Absence of on-site surgery
 Lesion morphology (related to initial success and restenosis rate)
Local (coronary artery) complications
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Reocclusion/restenosis
Coronary Dissection and abrupt closure after PTCA
Intramural hematoma
Perforation of heart or great vessels
Distal embolization
Complications seen with stenting
o Abrupt vessel closure
o Failure of stent deployment
o Stent thrombosis
o Stent infection
 MYOCARDIAL ISCHEMIA
 Emergency CABG for failed PCI
Vascular Complications
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Access site bleeding
Retroperitoneal bleeding
Atheroembolism
Hematoma formation
Retroperitoneal extension
Arteriovenous fistula
Pseudoaneurysm
 Arterial thrombosis
OTHER
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Acute renal failure
Stroke
Anticoagulation-associated bleeding
Ventricular arrhythmia
Infection
Radiation exposure
Peripheral arterial disease
Allergic reaction to dye exposure
Medical therapy post-stenting
Bare metal stent
 ASA 162-325 mg/d at least 1 mo, 75-162 mg/d indefinitely (I, A)
 AND clopidogrel 75 mg/d, at least 1 mo (I, A), ideally up to 1 yr (I, B)
Drug-eluting stent
 ASA 162-325 mg/d at least 3 (sirolimus)-6 (paclitaxel) mo, 75-162 mg/d
indefinitely (I, A) AND
 clopidogrel 75 mg/d at least 1 yr (I, B)
Contraindications to angioplasty stenting (at time of angiography)
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Unprotected left main stenoses
Old total occlusions
Diffusely diseased vessels
o Native coronaries
o Old saphenous vein grafts
Marked arterial ectasia with stenoses
Contraindications: patient conditions (relative
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Severe infection, sepsis
Recent neurological event
Significant hemorrhagic diathesis
Renal failure
Allergy to contrast media