Percutaneous Coronary Intervention — Procedure Guide, Recovery & Risks | MyMedicPlus

Percutaneous coronary intervention (PCI, formerly angioplasty) is a catheter-based procedure to restore blood flow through obstructed coronary arteries caused by atherosclerotic plaque build-up. A balloon catheter expands the blocked arterial segment and a drug-eluting stent (DES) is deployed to scaffold the artery open and prevent re-narrowing. PCI is used for both stable angina refractory to medical therapy and acute coronary syndromes — including NSTEMI and STEMI (ST-elevation myocardial infarction), where rapid restoration of coronary flow is life-saving. It is one of the most frequently performed interventional cardiac procedures globally, with over 1.5 million procedures performed annually in the USA alone, and has been central to the dramatic reduction in acute MI mortality over the past 30 years. PCI is performed by interventional cardiologists in a cardiac catheterisation laboratory equipped with fluoroscopy and emergency resuscitation facilities. Success rates exceed 95% for elective procedures. Technical innovations including drug-eluting stents (DES) — second and third generation — coated with antiproliferative drugs (everolimus, zotarolimus, sirolimus) have reduced in-stent restenosis to under 5%, transforming PCI from a palliative to a durable revascularisation strategy. Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) provide intracoronary imaging to guide stent sizing and placement, optimising outcomes by minimising stent under-expansion and edge dissection.

PCI is indicated for STEMI as primary reperfusion therapy (target: within 90 minutes of first medical contact), NSTEMI or unstable angina with high-risk features (elevated troponin, dynamic ST changes, haemodynamic instability, or TIMI risk score 5 or above), stable angina with obstructive coronary disease (70% or greater stenosis) causing symptoms or significant ischaemia on non-invasive testing (FFR or iFR under 0.80), and in-stent restenosis after prior PCI. PCI is suitable for single-vessel or selected two-vessel disease; three-vessel disease or left main coronary stenosis may be better served by coronary artery bypass grafting (CABG) based on SYNTAX score assessment. Patients with recent MI and multivessel disease are managed by staged PCI of the culprit vessel first, with subsequent staged PCI of non-culprit vessels at a planned interval.

PCI is performed in a cardiac catheterisation laboratory by an interventional cardiologist under continuous fluoroscopic guidance and haemodynamic monitoring. The procedure typically takes 45-90 minutes for single-vessel interventions and up to 2-3 hours for complex multi-vessel or chronic total occlusion (CTO) cases.

Pre-procedure preparation: Patients receive aspirin 300 mg and a P2Y12 inhibitor (ticagrelor 180 mg, clopidogrel 600 mg, or prasugrel 60 mg) as antiplatelet loading before the procedure. Unfractionated heparin (70-100 IU/kg) or bivalirudin is administered intravenously for procedural anticoagulation. IV pre-hydration reduces contrast nephropathy risk in patients with renal impairment.

Arterial access: The radial artery at the wrist (right or left) is the preferred access route at most centres due to substantially lower major bleeding risk (0.5% vs 2-3% femoral), earlier ambulation, shorter hospital stay, and similar or superior clinical outcomes demonstrated in multiple randomised trials including MATRIX and RIVAL. The femoral artery is used for complex procedures requiring larger-bore catheters (7-8 French), haemodynamic support devices (IABP, Impella), or when radial anatomy is unfavourable. Ultrasound guidance reduces access complications.

Coronary engagement and diagnostic angiography: A 5-7 French guiding catheter is advanced under fluoroscopy through the aorta to engage the left or right coronary ostium. Injection of iodinated contrast opacifies the coronary tree, characterising stenosis severity, morphology (length, calcification, angulation, bifurcation involvement, thrombus burden), and distal vessel territory. Fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) pressure wire measurements provide haemodynamic assessment for intermediate lesions (40-70% stenosis) where angiographic severity is not reliable.

Lesion crossing: A 0.014-inch coronary guidewire is advanced beyond the stenosis and positioned distally in the target vessel. Wire choice depends on lesion complexity: standard polymer-jacketed wires for most lesions; specialised stiff-tip or tapered-tip wires for chronic total occlusions requiring antegrade dissection re-entry or retrograde via collateral approaches.

Balloon pre-dilatation and stent delivery: A semi-compliant balloon catheter dilates the stenosis at 6-16 atmospheres before stent delivery. Drug-eluting stents (DES) -- pre-mounted on a balloon catheter and eluting antiproliferative drugs (everolimus, sirolimus, zotarolimus) from polymer matrices -- are deployed at 10-14 atmospheres. Post-dilatation with a non-compliant balloon at 18-24 atmospheres ensures complete stent expansion and wall apposition. Intravascular imaging (OCT or IVUS) guides optimisation in complex cases.

Haemostasis: The radial sheath is removed and a TR Band compression device applied for 2-4 hours before deflation. Femoral access sites are closed with a collagen plug or suture closure device, or with manual compression for 20-30 minutes.

PCI relieves angina symptoms in over 90% of patients with obstructive coronary disease. Primary PCI for STEMI reduces 30-day mortality by 25–30% compared with thrombolytic therapy and is the gold-standard reperfusion strategy when performed within the recommended time window. Drug-eluting stents achieve 5-year target lesion revascularisation rates under 8%, dramatically lower than bare-metal stent restenosis rates of 20–30%. For single-vessel stable coronary disease, PCI provides superior symptom relief compared with optimal medical therapy alone (ORBITA-2 trial). Long-term survival outcomes for single-vessel PCI are equivalent to CABG in appropriately selected patients. For elective PCI in stable angina, PCI reduces anginal symptoms and improves exercise capacity compared to medical therapy, though it has not been shown to reduce mortality or myocardial infarction risk in stable disease (COURAGE, ORBITA, ISCHEMIA trials). FFR (fractional flow reserve)-guided PCI targets only haemodynamically significant lesions, improving outcomes and reducing unnecessary stenting.

Access-site complications with radial access are significantly less frequent than with femoral access — major bleeding 0.5% vs 2–3%. Contrast-induced nephropathy occurs in 1–3%, particularly in patients with pre-existing renal impairment; IV hydration before and after the procedure is standard prevention. Coronary artery dissection occurs in under 1% and is usually managed with additional stenting. Stent thrombosis — a rare but potentially fatal complication — occurs in under 1% of patients at 30 days when DAPT is taken correctly; premature DAPT discontinuation is the strongest risk factor. In-stent restenosis affects 5–10% of DES-treated lesions at 5 years. Stroke occurs in under 0.3% and emergency surgical bypass in under 0.2% of elective PCI procedures. Contrast-induced acute kidney injury occurs in 2–10% of patients, particularly those with pre-existing renal impairment — hydration protocols and minimising contrast volume reduce risk. Radiation exposure from fluoroscopy is managed with dose optimisation techniques. Stent thrombosis — rare (under 1% annually) but potentially catastrophic — is prevented by dual antiplatelet therapy compliance. Drug-eluting stent thrombosis may occur late (after 1 year) if antiplatelet therapy is prematurely discontinued.

Radial access allows ambulation within 2–4 hours of the procedure and same-day or next-day discharge in stable elective PCI. Most patients are discharged within 1–2 days. Dual antiplatelet therapy (DAPT) with aspirin plus a P2Y12 inhibitor — clopidogrel, ticagrelor, or prasugrel — is prescribed for 6–12 months after elective stenting and 12 months after ACS to prevent stent thrombosis. DAPT must never be stopped without consulting the treating cardiologist. Driving is permitted after 1 week for stable PCI and after cardiac rehabilitation clearance for ACS. Strenuous activity and heavy lifting are avoided for 4–6 weeks. Cardiac rehabilitation improves functional capacity and reduces cardiac event recurrence after ACS by 26% and should be offered to all PCI patients. Dual antiplatelet therapy (DAPT) — aspirin plus a P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) — is mandatory for at least 6–12 months after drug-eluting stent implantation to prevent stent thrombosis. Early discontinuation for non-cardiac surgery should be discussed with the cardiologist. Annual cardiology review including exercise testing or stress imaging assesses stent patency and overall cardiovascular risk management.