Percutaneous coronary intervention (PCI) is an interventional technique and procedure used to treat coronary arteries that present with significant stenosis or complete occlusion. This procedure aims to restore normal blood flow to the heart and relieve angina symptoms associated with underlying coronary artery disease, such as chest pain (tightness, heaviness, pressure), shortness of breath, a burning sensation in the upper abdomen, and fatigue.
Below is a detailed presentation of the procedure, the required preparation, and the potential complications and cost of treatment.
What is percutaneous coronary intervention (PCI)?
Percutaneous coronary intervention (PCI) is an invasive procedure that aims to open stenoses and acute or chronic occlusions of the coronary arteries in order to restore normal blood flow and supply to the myocardium (heart).
The technique involves the use of specialized balloons and metallic or bioresorbable stents, whose placement restores normal blood flow and improves cardiac function. PCI is usually performed under local anesthesia (the patient is awake), using a special catheter inserted through an artery in the wrist (radial artery) or the leg (femoral artery).
What preparation is needed before PCI?
Before PCI, a full clinical evaluation is necessary, which usually includes blood tests (complete blood count, renal function, electrolytes) and cardiac function assessment via echocardiography and electrocardiogram.
Additionally, a non-invasive anatomical or functional assessment is typically performed beforehand, such as coronary CT angiography, stress echo, myocardial perfusion imaging, or exercise testing, which raises strong suspicion of significant coronary artery stenoses. This is followed by diagnostic coronary angiography and other invasive diagnostic methods (intravascular imaging and functional assessment of epicardial coronary circulation), which precisely determine the stenoses requiring treatment.
The patient may need to stop certain medications 24–48 hours before the procedure, based on the instructions of the interventional cardiologist performing the procedure.
The patient no longer needs to fast before the intervention; fluid and solid food intake is permitted unless the procedure is performed under general anesthesia or deep sedation.
Before the procedure, hair is removed from the access site (wrist or leg), an IV line is placed to allow intravenous drug administration, and the patient is hydrated with IV normal saline.
Additionally, patients are given antiplatelet medications to prevent thrombus formation within the vessel after stent placement and PCI.
PCI: The Procedure
PCI is performed using specialized balloon catheters, which are inflated to open stenoses within the coronary arteries. In certain cases with highly complex lesions and significant calcification, specific plaque modification techniques such as intravascular lithotripsy or rotational atherectomy are used to achieve adequate plaque modification and ensure optimal stent expansion.
Modern PCI is now guided by advanced intravascular imaging techniques (IVUS/NIRS/OCT), allowing for precise assessment of the size, location, composition, and burden of the atherosclerotic plaque. This enables accurate stent placement only in lesions truly responsible for the patient’s symptoms (precision PCI). In addition, after PCI, the therapeutic outcome is reassessed with repeat intravascular imaging (IVUS/OCT) to confirm proper stent expansion and apposition, minimizing the risk of future restenosis. Strong clinical data show that intravascular imaging-guided PCI significantly reduces stent failure.
The patient typically stays overnight in the hospital under continuous ECG monitoring, can mobilize and eat immediately, and is discharged fully functional without restrictions the next day.
Drug-Eluting Balloon Angioplasty
PCI can also be performed without placing a stent, using a special drug-coated balloon (DCB). This limits the number and total length of metallic stents implanted, thus reducing the amount of permanent material left inside the vessel wall. The goal is to preserve the natural properties and vasomotion of the coronary arteries and eliminate the risk of in-stent restenosis.
This technique requires intravascular imaging to confirm adequate lesion dilation and minimize the risk of recoil. Additionally, special balloons such as cutting or scoring balloons are used to ensure proper lesion preparation.
Following inflation of the drug-eluting balloon, a specific drug is released into the vessel wall, preventing restenosis and potentially promoting mid- and long-term vessel enlargement (positive remodeling).
PCI with Stent Placement
After successful balloon dilation of a coronary artery stenosis, one or more metallic stents are implanted at the site. A stent is a small metallic device that remains permanently in place, preventing restenosis and keeping the artery open to avoid immediate recoil.
The use of stents has significantly reduced the incidence of recurrent stenoses and improved treatment outcomes. Stent placement is guided by intravascular imaging (IVUS or OCT) to ensure proper positioning and full expansion and apposition of the stent to the vessel wall.
PCI with Bioresorbable Scaffolds
PCI can now be performed using special bioresorbable scaffolds that are fully absorbed within 12 months, leaving no permanent material inside the vessel wall, unlike conventional metallic stents.
The advantage of this technique is the full opening of the artery, prevention of immediate recoil due to scaffold support, and full restoration of the vessel’s natural properties after the scaffold is absorbed within a year.
This technique offers significant advantages, particularly in younger patients for whom avoiding permanent metallic stents is desirable. However, the use of bioresorbable scaffolds is limited by their lower radial strength compared to metallic stents, and in heavily calcified plaques, full expansion and proper apposition may not be achieved. Their expansion range is also more limited than that of metallic stents.
Are there complications after PCI?
PCI is generally a safe procedure, but rare complications (<1%) may occur. These include bleeding, hematomas, and bruising at the catheter insertion site (a risk minimized with radial access due to the small size of the radial artery and ultrasound-guided puncture), allergic reactions to the contrast agent used during the procedure, stroke, cardiac arrhythmias, acute myocardial infarction, vascular injury from catheter and wire manipulation, and acute kidney injury from contrast use. However, PCI can now be performed without contrast using intravascular imaging (zero-contrast PCI).
The risk of complications is minimized by using advanced diagnostic and therapeutic techniques, state-of-the-art equipment and materials, and proper patient preparation.
What is the cost of treatment?
The cost of PCI can vary depending on the complexity of the procedure and the number and type of specialized materials used.
Overall, PCI is an effective and minimally invasive method for treating coronary artery stenoses, aiming to improve cardiovascular health and prognosis and provide immediate relief from the symptoms of coronary artery disease.
