Patient Management, Protected PCI
Standardized Pre-Procedural Clinical Workup for Protected Percutaneous Coronary Intervention
by Fadi Al-Rashid, Nicolas M. Van Mieghem, Laurent Bonello, Jacopo Oreglia, Enrico Romagnoli
Pre-procedural assessment is important in the complex patient population undergoing Protected PCI. Identifying and preparing the femoral access site is a critical aspect of this workup. This article describes pre-procedural preparation, with a particular focus on imaging techniques for screening and guiding vascular access in patients undergoing Protected PCI.
The authors describe the roles of the multidisciplinary team—cardiologists/cardiac intensivists, echocardiographers, interventional cardiologists, anesthesiologists, and vascular surgeons—during the workup for elective/urgent high-risk PCI and provide a pre-procedural clinical workup algorithm for screening patients requiring Protected PCI. They describe the roles for conventional angiography, computed tomography, and vascular ultrasound in pre-procedural screening.
All Protected PCI patients undergo coronary angiography during pre-procedural evaluation. It is readily available and useful for identifying key anatomic landmarks. Digital subtraction angiography (DSA) is the gold standard and can enhance image quality and minimize the use of contrast dye. Angiography, however, provides a limited evaluation of vessel tortuosity and the degree of atherosclerotic disease.
"In selected cases, it may be important to combine several imaging techniques to achieve optimal femoral access. [...]"
Computed tomography (CT) can help overcome the limitations of conventional angiography and DSA by accurately assessing vessel dimensions, tortuosity, calcification, and plaque. This is particularly useful in patients with aortic aneurysm or peripheral vascular disease. CT, however, may not be available in all settings, requires approximately 80-120 mL of contrast, and may overestimate calcification in vessels.
Vascular ultrasound can provide a real-time view of the landscape during vascular access and assess both plaque and calcification at the access site without the use of additional radiation or contrast dye. This makes it particularly useful for challenging vascular access and in patients at high risk for complications. Vascular ultrasound helps operators readily identify high common femoral artery (CFA) bifurcations and can aid in visualizing needle trajectory. The authors write, “The ultrasound-guided vascular access technique is an important asset in large-bore, catheter-based endovascular interventions and ensures successful closure (…) ultrasound is essential in multimodality access evaluation, and complements angiography and CT.” Use of vascular ultrasound, however, may be limited by ultrasound availability in the cath lab and limited visualization in patients with obesity.
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