Seminar PCI

Percutaneous Coronary
Intervention
Failures vs. Complications
J. Matthew Brennan, MD, MPH

Assistant Professor of Medicine, Interventional Cardiology
Duke University Medical Center
9/28/2013
No Disclosures
All Rights Reserved, Duke Medicine 2007

Overview
• Cardiac Cath, 21st Century
• Percutaneous Coronary Intervention (PCI)
– Measuring success
• Cardiac Cath, Mechanical Complications
– Vascular Complications
– Catheter Entrapment
– Coronary Dissection
– PCI failures vs. complications
• The ‘Thin Red Line’
Learning Objectives
• What is a ‘PCI success’?

• What is the difference between PCI ‘failure’
& PCI ‘complication’?
GENERAL OBJECTIVES
 Review updates to STS ACSD Data Collection Form
 Increased familiarity with coding CABG Indications
and Operative Status

History of Cardiac Catheterization
• Werner Forssmann – 1929 Incised his left antecubital vein
and fed a catheter 65 cm into his RA, walked down to
radiology for X-ray
Fired from job, shared 1956 Nobel prize for Medicine and
Physiology with Cournand and Richards
Cardiac Cath Lab, 21st Century

Coronary Angiography

Percutaneous Coronary Intervention (PCI)
90% mid-LAD lesion Stent Deployment
“A percutaneous coronary intervention (PCI) is the placement of an

angioplasty guide wire, balloon, or other device (e.g. stent, atherectomy,
brachytherapy, or thrombectomy catheter) into a native coronary artery or
coronary artery bypass graft for the purpose of mechanical coronary
revascularization.” --NCDR CathPCI
Coronary devices

Overview
Overview
What is ‘PCI Success’?
A. Relief of ischemic symptoms (e.g., angina, CHF)

B. Residual angiographic stenosis <50%, TIMI 3 flow,
no major side-branch occlusion
C. Residual angiographic stenosis <10%, TIMI 3 flow,
no major side-branch occlusion
D. Stent deployment without major in-hospital
complications

“The eye of the beholder…”
15 y/o F with SCD playing softball

• Successful Resuscitation
• Transferred to DUMC for work-up and treatment
PMHx
• None of interest

“The eye of the beholder…”
PROCEDURE
• Residual 20-30% mid-LAD lesion
INHOSPITAL
• Full recovery
• AICD placed without complication
6 MONTHS POST-PCI:
• Active high-school student
• No residual symptoms or SCD episodes

Was this a Successful PCI?
A. Yes
B. No
C. Don’t know

What is PCI Success?
ANGIOGRAPHIC SUCCESS
• Residual stenosis <10%, TIMI 3 flow, no occlusion of
a significant side-branch, flow-limiting dissection,
distal embolization, or angiographic thrombus.
PROCEDURAL SUCCESS
• Angiographic success without in-hospital major
complications (e.g., death, MI, stroke, emergent
CABG)
CLINICAL SUCCESS
• Procedural success with relief of signs and/or
symptoms of myocardial ischemia.

Overview
Overview
Complications of Catheterization and PCI
Major Complications CathPCI

Registry (%)
Mortality 0.11
Myocardial infarction 0.05
Cerebrovascular accident 0.07
Arrhythmias 0.38
Vascular complications 0.40
Contrast reaction 0.37
Hemodynamic complications 0.26
Perforation 0.03
Other complications 0.28
J Am Coll Cardiol 1999:33:1756 TOTAL MAJOR COMPLICATIONS 1.70

Vascular Complications
Access Site
Vascular Dissection
Vascular Perforation

Catheter Entrapment
J INVASIVE CARDIOL 2012;24(1):E3-E4

Catheter Entrapment
J INVASIVE CARDIOL 2012;24(1):E3-E4

Vascular Complications
Aortic Dissection
N Engl J Med 2010; 363:e18

Coronary
Dissection
LCA
48 y/o with h/o PCI (3v)
• Admitted with UA
• Nuclear Stress w/
Inferior Ischemia
Procedure
• Dx JR5, JL3.5
RCA
• AL 0.75 Guide
• Intended FFR

Coronary Perforation
Circ Cardiovasc Imaging 2008;1:e7-e8 J Am Coll Cardiol Intv 2011;4:87-95

Overview
Overview
Failed PCI, Urgent or Emergent CABG
Failed PCI to CABG Isolated CABG,
(NCDR CathPCI, 2012) Indications
8000 (STS ACSD, 2011-13)
1500
6000
Cath Cases
6299
1000 1170
4000
500 671
2000 2826
170
0
PCI failure, Angio Angio
0 no Accident Accident
PCI PCI failure deterioration
Complication (w/o det) Urgent Emergent
PCI Complications. Estimated ~1-3/yr per hospital

Data Spec Updates
Status:  Elective  Urgent  Emergent  Emergent Salvage

If Urgent or Emergent choose one reason
 AMI  PCI Incomplete without clinical deterioration
 AEMI  PCI or attempted PCI with Clinical Deterioration
 Anatomy  Pulmonary Edema
 Aortic Aneurysm  Rest Angina
 Aortic Dissection  Shock Circulatory Support
 Cardiac Transplant  Shock No Circulatory Support
 CHF  Syncope
 Device Failure  Transplant
Diagnostic/Interventional Trauma
 Procedure Complication 
 Endocarditis  USA
Failed Transcatheter Valve Valve Dysfunction
 Therapy 
 IABP  Worsening CP
 Infected Device  Other
 Ongoing Ischemia 

How would you code this case?
74 y/o M with stable angina.

Admitted for CABG.
A. Elective
B. Urgent
C. Emergent
D. Salvage
90% LM, 90% ostial LCx,

80% ostial LAD (L-dom)
Urgent vs. Emergent vs. Salvage
Operations
URGENT
• Procedure required during same hospitalization in order to
minimize chance of further clinical deterioration
EMERGENT
• Patients requiring emergency operations will have ongoing,
refractory (difficult, complicated, and/or unmanageable)
unrelenting cardiac compromise, with or without hemodynamic
instability, and not responsive to any form of therapy except
cardiac surgery.
SALVAGE
• The patient is undergoing CPR en route to the OR or prior to
anesthesia induction or has ongoing ECMO to maintain life.

83 y/o M presents with
ongoing typical angina
• Symptoms on Nitro gtt in
ER
• EKG: ST depressions
PMHx
• PCI to mid-RCA, OM2 3
yrs prior (DES)
Angiogram
• RCA thought to potentially
be acute vessel
Post-PCI Course
• Symptoms & EKG
resolved during procedure;
no IABP
• Referred (eventually) for
outpt CABG
Code this surgical case…
A. Elective: PCI Incomplete without Clinical

Deterioration
B. Elective: Diagnostic/Interventional Procedure
Complication
C. Urgent: PCI Incomplete without Clinical
Deterioration
D. Emergent: Unstable Angina (USA)
E. Don’t know

When ‘good’ is the enemy of ‘good enough’…
THE ‘THIN RED LINE’

67 y/o F with UA
@ OSH
• No prior PCI
• No sig. PMHx
ANGIOGRAM:
90% mid-LAD lesion

“The Thin Red Line”
“Sometimes you only know what is enough

by learning what is too much…”
Code this surgical case…
A. Emergent: PCI with clinical deterioration

B. Emergent: Diagnostic/Interventional Procedure
Complication
C. Salvage: Diagnostic/Interventional Procedure
Complication
D. Salvage: Shock without circulatory support
E. Don’t know

Consequences of complacency…
ROUTINE IS NEVER ROUTINE

86y/o M w/ recurrent UA
• COPD, home O2
• Met. prostate CA
• 30 HB: DDD pacer
• DNR/DNI
 Suspended for
cath/possible PCI

Shock: Clinical Management
• IV Fluids
• Pressors
• Pericardiocentesis
Stabilization:
 Active drainage
 Intubation
 Blood transfusion
 Bivalirudin off Stabilization:
Ad Hoc Recirculation: • Family & CV surgery
consultation
 5 Fr right IJ line
• Hypertension
 Pericardial drain to IJ line
2 hours auto-transfusion • Re-bleeding
• Death

Learning Objectives
• What is a ‘PCI success’?

• What is the difference between PCI ‘failure’
& PCI ‘complication’?
GENERAL OBJECTIVES
 Review updates to STS ACSD Data Collection Form
 Increased familiarity with coding CABG Indications
and Operative Status

Thank You!
J. Matthew Brennan, MD, MPH

Assistant Professor of Medicine, Interventional Cardiology
Duke University Medical Center
9/28/2013

Seminar PCI

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Percutaneous Coronary

J. Matthew Brennan, MD, MPH

All Rights Reserved, Duke Medicine 2007

• What is a ‘PCI success’?

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

“A percutaneous coronary intervention (PCI) is the placement of an

All Rights Reserved, Duke Medicine 2007

A. Relief of ischemic symptoms (e.g., angina, CHF)

All Rights Reserved, Duke Medicine 2007

15 y/o F with SCD playing softball

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

Major Complications CathPCI

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

J INVASIVE CARDIOL 2012;24(1):E3-E4

J INVASIVE CARDIOL 2012;24(1):E3-E4

N Engl J Med 2010; 363:e18

All Rights Reserved, Duke Medicine 2007

Circ Cardiovasc Imaging 2008;1:e7-e8 J Am Coll Cardiol Intv 2011;4:87-95

All Rights Reserved, Duke Medicine 2007

PCI Complications. Estimated ~1-3/yr per hospital

Status:  Elective  Urgent  Emergent  Emergent Salvage

All Rights Reserved, Duke Medicine 2007

74 y/o M with stable angina.

90% LM, 90% ostial LCx,

All Rights Reserved, Duke Medicine 2007

A. Elective: PCI Incomplete without Clinical

All Rights Reserved, Duke Medicine 2007

THE ‘THIN RED LINE’

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

“Sometimes you only know what is enough

A. Emergent: PCI with clinical deterioration

All Rights Reserved, Duke Medicine 2007

ROUTINE IS NEVER ROUTINE

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

All Rights Reserved, Duke Medicine 2007

• What is a ‘PCI success’?

All Rights Reserved, Duke Medicine 2007

J. Matthew Brennan, MD, MPH

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