1. Is it dangerous to perform PCI at institutions without cardiac surgery capabilities? No. No it's not. The CPORT-E trial randomized 18,000 to PCI at hospitals with and without on-site cards surg.
- 6-week mortality rate was 0.9% vs 1.0% (P=0.004 for noninferiority).
- 9-month rates of major adverse cardiac events were 12.1% and 11.2% (P=0.05 for noninferiority).
- rate of target-vessel revascularization was higher in hospitals without on-site surgery (6.5% vs. 5.4%, P=0.01).
{NEJM, 2012)
2. Predicting in-hospital mortality after PCI: the NCDI CathPCI risk score system, developed on a dataset with N of 180,000, and validated on 2 different sets of data (n=120,000 and n=280,000). Not only is this data highly powered, it's also reflects modern practice (2004 to 2006 data), is nationally representative, and reflects a good proportion of acute and stable cases. {JACC, 2010)

3. Periprocedural complications of PCI: stent thrombosis 

- Incidence of intraprocedural stent thrombosis - 0.8% (per post hoc data analysis on CHAMPION-PHONENIX trial n=10,000)
- Presents clinically as an acute MI, +/- STEMI
- Can also accur subacute (within 30 days) or chronically (years)
4. Periprocedural complications of PCI: contrast nephropathy
- A good percent of people undergoing PCI will get renal damage from the contrast load, particularly if they have underlying disease
- The good news is that the POSEIDON trial showed that hydration (titrating to LVEDP) can significantly reduce the renal injury
5. Periprocedural complications of PCI: stroke
- Pushing a guide wire around the aorta (full of atherosclerotic plaques in many) is unsurprisingly a risk factor for stroke.
- Study examining incidence of stroke after PCI {Circulation, n=46,000, 2005-2008 data, published 2013}
- Stroke was observed in 0.4% of the procedures in the total population, in 0.3% of PCIs in elective patients, and in 0.6% in PCIs performed for ACS.
- Overall in-hospital mortality was 19.2% for patients who developed stroke (elective PCIs, 10.0%; PCI for ACS, 23.2%) compared with 1.3% for those without stroke (elective PCIs, 0.2%; PCI for ACS, 2.3%).
- In multivariate analysis hemodynamic instability, age ≥75 years, history of stroke, and congestive heart failure were found to be independent predictors for periprocedural stroke in ACS, whereas only PCI of a bypass graft and renal failure could be identified as independent predictors for stroke in elective patients.
6. Periprocedural complications of PCI: Coronary artery dissection 

- Given that you're opening a balloon within a stenotic vessel aiming to expand it, it's no surprised that the plaques crack, and sometimes lead to vessel dissections

- A and B dissections are considered benign, while the others could be more dangerous 

7. Periprocedural complications of PCI: Perforation 

- In a study {Am J Cardiol, n=10,000, data from years 1993 to 2001}, reported incidence of perforation was 0.84%. 

- The worse the perforation, the worse the complications/outcomes

- Management: emergent pericardiocentesis if tamponade results

- Typically, tamponade will occur 6-8 hours after the procedure 

8. Periprocedural complications of PCI: Retroperitoneal hemorrhage 

- If you hit the back wall of the femoral artery above the inguinal ligament, you can get a retropertioneal hemorrhage that is not amenable to compression 

- Will manifest clinically as hypotension and tachycardia after a procedure 

- One of the most common causes of mortality after PCI

- Don't trust the groin-- just because it looks clean and perfect does NOT mean there is not a giant retroperitoneal hematoma. 

9. Periprocedural complications of PCI: vascular site bleeding

- Now the new trend is to use radial rather than femoral access, as it is compressible. 

Lancet. 2011 Apr 23;377(9775):1409-20. doi: 10.1016/S0140-6736(11)60404-2. Epub 2011 Apr 4.

Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial.

METHODS:

The RadIal Vs femorAL access for coronary intervention (RIVAL) trial was a randomised, parallel group, multicentre trial. Patients with ACS were randomly assigned (1:1) by a 24 h computerised central automated voice response system to radial or femoral artery access. The primary outcome was a composite of death, myocardial infarction, stroke, or non-coronary artery bypass graft (non-CABG)-related major bleeding at 30 days. Key secondary outcomes were death, myocardial infarction, or stroke; and non-CABG-related major bleeding at 30 days. A masked central committee adjudicated the primary outcome, components of the primary outcome, and stent thrombosis. All other outcomes were as reported by the investigators. Patients and investigators were not masked to treatment allocation. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, NCT01014273.

FINDINGS:

Between June 6, 2006, and Nov 3, 2010, 7021 patients were enrolled from 158 hospitals in 32 countries. 3507 patients were randomly assigned to radial access and 3514 to femoral access. The primary outcome occurred in 128 (3·7%) of 3507 patients in the radial access groupcompared with 139 (4·0%) of 3514 in the femoral access group (hazard ratio [HR] 0·92, 95% CI 0·72-1·17; p=0·50). Of the six prespecified subgroups, there was a significant interaction for the primary outcome with benefit for radial access in highest tertile volume radial centres (HR 0·49, 95% CI 0·28-0·87; p=0·015) and in patients with ST-segment elevation myocardial infarction (0·60, 0·38-0·94; p=0·026). The rate of death, myocardial infarction, or stroke at 30 days was 112 (3·2%) of 3507 patients in the radial group compared with 114 (3·2%) of 3514 in the femoral group (HR 0·98, 95% CI 0·76-1·28; p=0·90). The rate of non-CABG-related major bleeding at 30 days was 24 (0·7%) of 3507 patients in the radial group compared with 33 (0·9%) of 3514 patients in the femoral group (HR 0·73, 95% CI 0·43-1·23; p=0·23). At 30 days, 42 of 3507 patients in the radial group had large haematoma compared with 106 of 3514 in the femoral group (HR 0·40, 95% CI 0·28-0·57; p<0·0001). Pseudoaneurysm needing closure occurred in seven of 3507 patients in the radial group compared with 23 of 3514 in the femoral group (HR 0·30, 95% CI 0·13-0·71; p=0·006).

INTERPRETATION:

Radial and femoral approaches are both safe and effective for PCI. However, the lower rate of local vascular complications may be a reason to use the radial approach.

10. Periprocedural complications of PCI: Anticoagulation-associated bleeding
- Generally, people are anticoagulated right before and during the procedure (to reduce clotting from balloon-mediated damage to the plaque, prevent immediate/acute rethrombosis)
- People are also anticoagulated after-- aspirin forever, plavix 30 days (BM stent in a stable patient) or 3-6 months (new drug eluting stents), or 12 months (old drug eluting stents, any stent in a patient experiencing acute MI)
- Such anticoagulation will cause all the typical anticoagulation bleeds (GI, access site, etc)