Cardiovascular Critical Care I
Nonsurgical – Details of interventional cardiology procedures are too broad to be discussed in great
detail in this chapter; however, the following are some considerations of the intervention that may play
a role in post-procedural management during a left heart catheterization and percutaneous coronary
intervention (PCI):
Access site
Radial artery (and, rarely, brachial artery) (Catheter Cardiovasc Interv 2011;78:840-6)
| (a) | Easily accessible |
|---|---|
| (b) | Increased risk of vasospasm during procedure |
| (c) | Easily compressible vessel when hemostasis is needed post-procedure |
| (d) | Does not prevent patient mobility post-procedure |
ii.
Femoral artery
| (a) | Easily accessible |
|---|---|
| (b) | More difficult to compress vessel when hemostasis is needed post-procedure and also |
associated with increased bleeding complications
| (c) | Limits patient mobility post-procedure for at least 12–24 hours (bleeding risk after sheath |
|---|
removal)
Common interventions performed:
Stent placement
| (a) | Important to note the number of stents placed, types of stents, and locations of placement |
|---|---|
| (b) | Bare metal stent |
| (1) | Requires single antiplatelet therapy with either aspirin or a P2Y12 antagonist for life |
and dual antiplatelet therapy (DAPT) for ideally 12 months after ACS, but shortened
durations of at least 1 month may be considered for patients at high risk of bleeding
| (2) | Longer therapies may be considered, depending on the number of stents and location(s) |
|---|
of the stent(s).
| (3) | Higher risk of in-stent stenosis over time (because of neointimal cell proliferation) |
|---|---|
| (c) | Drug-eluting stent |
| (1) | Requires single antiplatelet therapy with either aspirin or a P2Y12 antagonist for |
life and DAPT for ideally 12 months after ACS, but shortened durations of at least
6 months may be considered for patients at high risk of bleeding longer or shorter
therapy durations may be considered, depending on the number and/or location(s)
of the stent(s) as well as patient bleeding risk. Some patients may benefit from a
modified DAPT regimen, such as discontinuing aspirin after 1–3 months of DAPT
and continuing with P2Y12 inhibitor monotherapy for the remaining 9–11 months
duration is necessary.
| (2) | The benefit of drug-eluting stents (i.e., everolimus, zotarolimus, biolimus) is the |
|---|
mitigation of in-stent restenosis, which is more common with bare metal stenting.
However, the rate of stent endothelialization is also impaired such that the risk of stent
thrombosis persists for a longer period. Consequently, drug-eluting stents mandate
longer-term DAPT than bare metal stents.
ii.
Thrombectomy: Thrombus aspiration generally followed by stent placement at site of lesion
iii.
Percutaneous transluminal coronary angioplasty (PTCA), also called “plain old balloon
angioplasty” (POBA): Balloon expansion and at least temporary displacement of occlusion at
site of lesion